Clinical Margin Width
Notes
**Note 1:** This SSDI is effective for diagnosis years 2023+ + For cases diagnosed 2018-2022, leave this SSDI blank **Note 2:** “The appropriate [wide local excision] margins are measured from the periphery of any gross residual tumor or the edges of the entire previous biopsy scar (shave or excisional).” Operative Standards for Cancer Surgery, Volume 2, page 392. **Note 3:** Code the peripheral surgical margins from the operative report from a wide excision + Do not use the pathology report to code this data item. + Margins from wide excision-Measured from the edge of the lesion or the prior excision scar to the peripheral margin of the specimen, do not use deep margin + Do not add margins together + If multiple wide excisions are performed, code the clinical margin width from the procedure with the largest margin. **Note 4:** Physician statement of clinical margin width can be used to code this data item when no other information is available, or the available information is ambiguous + Order of priority: - Operative Note - Physician statement in medical record **Note 5:** Record stated margin in centimeters. Include decimal point. *Examples:* + 0.5 cm - 0.5 + 1 cm- 1.0 + 2.5 cm - 2.5| Code | Description |
|---|---|
| 0.1 | Documented as 0.1cm or less (1mm or less) |
| 0.2-9.9 | 0.2 cm – 9.9 cm |
| XX.1 | 10 centimeters or greater |
| XX.8 | Not Applicable. Information not collected for this schema (If this information is required by your standard setter, use of code XX.8 may result in an edit error) |
| XX.9 | Not documented in medical record No Wide Excision performed Mohs or similar procedure Wide Excision performed, but clinical margin width not documented. No surgical resection performed (B000) Unknown if procedure performed. |
| <BLANK> | N/A-Diagnosis year is prior to 2023. |