Note 1: Usually prostate cancers are graded using Gleason's score or pattern.Gleason's grading for prostate primaries is based on a 5-component system (5 histologic patterns).Prostatic cancer generally shows two main histologic patterns.The primary pattern that is, the pattern occupying greater than 50% of the cancer is usually indicated by the first number of the Gleason's grade and the secondary pattern is usually indicted by the second number.These two numbers are added together to create a pattern score, ranging from 2 to 10.If there are two numbers, assume that they refer to two patterns (the first number being the primary and the second number being the secondary) and sum them to obtain the score. If only one number is given and it is less than or equal to 5, assume that it describes a pattern and uses the number as the primary pattern and code the secondary as '9'.If only one number is given and it is greater than 5, assume that it is a score.If the pathology report specifies a specific number out of a total of 10, the first number given is the score.Example:The pathology report says "Gleason's 3/10".The Gleason's score would be 3.
Note 2: Following AJCC guidelines for coding multiple Gleason's Scores in prostate cancer, if there is more than one primary and secondary pattern value, the value to be coded is the one based on the larger tumor specimen.Please note that this rule is not the same as the rule for coding grade.
| Code | Description |
|---|---|
| 000 | Test not done (test was not ordered and was not performed) |
| 011 | Primary pattern 1, secondary pattern 1 |
| 012 | Primary pattern 1, secondary pattern 2 |
| 013 | Primary pattern 1, secondary pattern 3 |
| 014 | Primary pattern 1, secondary pattern 4 |
| 015 | Primary pattern 1, secondary pattern 5 |
| 019 | Primary pattern 1, secondary pattern 9 |
| 021 | Primary pattern 2, secondary pattern 1 |
| 022 | Primary pattern 2, secondary pattern 2 |
| 023 | Primary pattern 2, secondary pattern 3 |
| 024 | Primary pattern 2, secondary pattern 4 |
| 025 | Primary pattern 2, secondary pattern 5 |
| 029 | Primary pattern 2, secondary pattern unknown |
| 031 | Primary pattern 3, secondary pattern 1 |
| 032 | Primary pattern 3, secondary pattern 2 |
| 033 | Primary pattern 3, secondary pattern 3 |
| 034 | Primary pattern 3, secondary pattern 4 |
| 035 | Primary pattern 3, secondary pattern 5 |
| 039 | Primary pattern 3, secondary pattern unknown |
| 041 | Primary pattern 4, secondary pattern 1 |
| 042 | Primary pattern 4, secondary pattern 2 |
| 043 | Primary pattern 4, secondary pattern 3 |
| 044 | Primary pattern 4, secondary pattern 4 |
| 045 | Primary pattern 4, secondary pattern 5 |
| 049 | Primary pattern 4, secondary pattern unknown |
| 051 | Primary pattern 5, secondary pattern 1 |
| 052 | Primary pattern 5, secondary pattern 2 |
| 053 | Primary pattern 5, secondary pattern 3 |
| 054 | Primary pattern 5, secondary pattern 4 |
| 055 | Primary pattern 5, secondary pattern 5 |
| 059 | Primary pattern 5, secondary pattern unknown |
| 099 | Primary pattern unknown, secondary pattern unknown |
| 999 | Unknown or no information Not documented in patient record |