Carbohydrate Antigen 19-9 Pretreatment Lab Value

Notes

**Note 1:** This SSDI is effective for diagnosis years 2021+ * For cases diagnosed 2018-2020, leave this SSDI blank **Note 2:** Physician statement of CA 19-9 (Carbohydrate Antigen 19-9) Pretreatment Lab Value can be used to code this data item when no other information is available. **Note 3:** Record the lab value of the highest CA 19-9 test result documented in the medical record prior to treatment. The lab value may be recorded in a lab report, history and physical, or clinical statement in the pathology report **Note 4:** A known lab value takes priority over codes XXXX.2 and XXXX.3 * The lab value takes priority even if the physician documents the interpretation * *Example:* Patient noted to have a CA 19-9 of 3,219. Physician notes that the value is elevated * Code 3219.0 instead of XXXX.3 (elevated) **Note 5:** CA 19-9 is a tumor marker that has value in the management of certain malignancies. **Note 6:** Record to the nearest tenth in Units/milliliter (U/ml), the highest CA 19-9 lab value documented in the medical record prior to treatment. * Example 1: Code a pretreatment CA 19-9 of 7 U/ml as 7.0 * Example 2: Code a pretreatment CA 19-9 of 1672.3 U/ml as 1672.3 **Note 7:** Record 0.1 when the lab results are stated as less than 0.1 U/ml with no exact value.

Default

XXXX.8

NAACCR Item

NAACCR #3942

Metadata

SSDI 2021–
Code Description
0.0 0.0 Units/milliliter (U/ml) exactly
0.1-9999.9 0.1-9999.9 U/ml (Exact value to nearest tenth in U/ml)
XXXX.1 10,000 U/ml or greater
XXXX.2 Lab value not available, physician states CA 19-9 is negative/normal
XXXX.3 Lab value not available, physician states CA 19-9 is positive/elevated/high
XXXX.7 Test ordered, results not in chart
XXXX.8 Not applicable: Information not collected for this case (If this information is required by your standard setter, use of code XXXX.8 may result in an edit error.)
XXXX.9 Not documented in medical record CA (Carbohydrate Antigen) 19-9 Pretreatment Lab Value not assessed or unknown if assessed
<BLANK> N/A - Diagnosis year is prior to 2021