Ulceration
This input is used for staging
Notes
**Note 1:** Physician statement of microscopically confirmed ulceration (e.g., based on biopsy or surgical resection) can be used to code this data item. **Note 2:** Ulceration can only be confirmed by microscopic examination. Do not use findings from physical exam. * It is possible for a patient to present with an ulcerated lesion noted on physical exam, but this is not the same thing as ulceration seen on a microscopic exam **Note 3:** Melanoma ulceration is the absence of an intact epidermis overlying the primary melanoma based upon microscopic (histopathological) examination. * Code 1 if any biopsy (punch, shave, excisional, etc.) or wide excision is positive for ulceration in the presence of an underlying melanoma * Code 0 if all specimens are negative OR one specimen is negative and the other is unknown * Ulceration must be caused by an underlying melanoma. Ulceration caused by trauma from a previous procedure should not be coded as positive for this SSDI **Note 4:** Code 9 if there is microscopic examination and there is no mention of ulceration. * This instruction **does** apply to non-invasive neoplasms (behavior /2)| Code | Description |
|---|---|
| 0 | Ulceration not identified/not present |
| 1 | Ulceration present |
| 8 | Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code 8 will result in an edit error.) |
| 9 | Not documented in medical record Cannot be determined by the pathologist Pathology report does not mention ulceration Ulceration not assessed or unknown if assessed |