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
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 |
