GATRA/GCCR Fall Conference 11/12/2012 November 14-16, 2012 … Abstracting Tips from the... · GATRA/GCCR Fall Conference November 14-16, 2012 11/12/2012 8 Before you assign 999,

GATRA/GCCR Fall Conference November 14-16, 2012

11/12/2012

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Georgia Center For Cancer StatisticsKim DeWolfe, MS, CTR

11/16/2012

Proper Text Documentation

Essential Rules for Abstracting

Collaborative Staging

Tips by Cancer Site


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See 2012 NAACCR Volume II Data Dictionary/Chapter X Recommended content by section http://www naaccr org/Applications/C http://www.naaccr.org/Applications/C

ontentReader/Default.aspx?c=10

You should be able to code from your text

Enter text in appropriate sectionEnter a date in each sectionUse abbreviations from approved listAvoid copy and pasteUse lower case characters Use punctuation


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When information missing from record, state it is missing

D t t i f ti f Do not repeat information from other text fields

Enter information relevant to primary site

Do NOT intermix text for simultaneous primaries

If O t f St t id t t ti f If Out of State resident at time of admit, address at dx should reflect this

For sequence >00, provide text to justify


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Saves time and limits length

MUST use NAACCR approved bb i ti li tabbreviation list

DO NOT make up your own terms

Located in Volume II of NAACCR’s Standards for Cancer Registries: http://www.naaccr.org/Applications/C

ontentReader/Default aspx?c=17ontentReader/Default.aspx?c 17Appendix G

GCCR/S is providing the list on a flash drive

Xray: “…intense act related to prim lesion RUL 2.2 cm spic mass pstv m lns bilat slight act Lt midlung corresponds to sml ill-def lesions on CT susp for to sml ill def lesions on CT susp for poss mets or 2nd prim act Rt sprclv susp for met Ln”


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X-ray: Chest CT 6/24/12: Primary lesion of RUL measuring 2.2 cm, described as spiculated. Positive bilateral mediastinal Lns Small ill-bilateral mediastinal Lns. Small illdefined lesion of Lt mid-lung is suspfor possible mets or 2nd primary. Activity in Rt supraclavicular region is susp for Ln mets.

PE (4/20/12): 67 yo wf presents to this facility for

lobectomy of a LLL lung primary. Patient diagnosed with

adenocarcinoma in Tallahassee FL adenocarcinoma in Tallahassee, FL via bronchoscopy.

Patient has prior hx of breast ca. Note: patient lived in Florida at time

of diagnosis. She has moved to Georgia to be closer to son.

X-ray/Scan: CT Chest/Abd/Pelvis (4/20/12): 14 mm LLL pulm nodule susp for neoplastic dz. Abd and Pelvis: No abnormalities.

CT Head (4/20/12):4.5 cm cystic mass in Lt ( ) ycerebellar hemisphere. Metasatic dz vs. hemangioblastoma.

Bone Scan(4/25/12): Scan is unremarkable with no evidence of bone mets.


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Lab Tests: 06/09/2012- PSA 5.9. Postop readmission CBC, 07/31/2011, WBC 12.90, RBC 3.79, HGB 11 7 HCT 35 2 Normal diff PtHGB 11.7, HCT 35.2, Normal diff. Ptw/previous hx of positive MRSA test at X medical center, unk details.

Lab Tests: 6/9/12 PSA = 5.9 ng/ml

Procedures from which staging info is derived

List biopsies and all other surgical proceduresprocedures

Surgeon’s observationsResidual tumor Invasion of surrounding areas


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DON’T limit to TNM

Organs involved by direct extension

Site(s) of Distant Mets

Physician’s specialty and comments

Let’s review togetherNote: there is a generic text

document on your flash drive


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Before you assign 999, look for a descriptor code

E l I i b t t Example: Invasive breast tumor described as microscopic focus

Correct Size code = 990

The most miscoded CS field

AVOID assigning “T nos” codes

Use best information whether clinical or pathologic

Document how the most extensive tumor established (clinical or pathologic)

Limit code 6 to tumors that are Limit code 6 to tumors that are more extensive than before neo-adjuvant therapy

Example: Tumor size larger after pre-operative chemotherapy


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Many are related to one another

With no edits in place currently, be t h k th t isure to check these twice

All codes should have text to accompany it SSF 7 for Breast coded to 080 =

“Bloom-Richardson Score of 8”

Read the general instructions of your manuals

MP/H Manual 2007

Collaborative Stage Part I


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Code histology and grade from the invasive component only

Exception: if grade is unknown for invasive component, you may use the in-situ grade

Record the earliest of any of these dates:

Date First Surgical ProcedureD t R di ti St t dDate Radiation Started

Date Systemic Therapy StartedDate Other Treatment Started

Primary siteRegional lymph nodes (FNA or core

bx)Di t t it t di t t l h Distant sites or to distant lymph nodes


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Lung Cancer Case

FNA of Mediastinal Lymph Node f d 11/06/2012performed 11/06/2012

LUL lobecotmy 12/12/2012

Date of First Course of Treatment = 11/06/2012

Indicate if this date is estimated

Use the first date whether clinical hi t l ior histologic

Clinical must contain reportable ambiguous terms

2/2/2012 Chest CT: 5 cm RUL lung nodule suspicious for carcinoma

3/15/2012 Right Upper Lung Lobectomy: poorly differentiated Lobectomy: poorly differentiated adenocarcinoma

What is the date of diagnosis? 2/2/2012Use first date containing reportable phrase


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Reportability

Staging/Involvement

Histology

Word Document on your Flash Drive

Let’s review it together


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62 yo bf with 4 cm mass arising in right kidney.

CT Abd: Large mass in right kidney consistent with renal cell carcinomaconsistent with renal cell carcinoma

Patient’s diagnostic work-up stopped after imaging studies performed and no treatment given

Is this case reportable?

Yes, due to the phrase: “consistent with renal cell carcinoma” in the radiology report

Ambiguous Diagnosis Code = 1 (diagnosed by ambiguous term only)

Surgeon describes a large colon mass kissing the adjacent duodenum

D thi l i l th Does this colon mass involve the duodenum?

No, kissing is not a term on the involvement list


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Pathology report for lung primary states: Non-small cell lung cancer suspicious for adenocarcinoma

Assign Adenocarcinoma histology Assign Adenocarcinoma histology code

“Suspicious for” is on the reportable ambiguous list

Use information in pathology report over other sources

V i b it d t it d Varies by site, data item, and situation

Consult site specific coding guidelines


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Step 1: Look for site specific coding guidelines for data field in question SEER’s Appendix C and CS Schemas If no rules apply proceed to Step 2 If no rules apply proceed to Step 2

Step 2: Refer to general coding instructions by data item Found in FORDS, SEER, and CS Part I

Use reports in the following order (resected sites):

1 O ti t ith g ’ 1. Operative report with surgeon’s description

2. Pathology report3. Imaging

Fuhrman grade

Nuclear grade

Terminology (well diff, mod diff)

Histologic grade (grade 1, grade 2)


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Refer to Breast Clock

Code multiple tumors to C50.9

Code large tumors to C50.8 If span over >1 quadrant

Don’t forget combination codes Infiltrating ductal ca with another

component

Code invasive component onlyCode invasive component onlyOften insitu and invasive cancer

present


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Tissue Expander NOT a type of tissue reconstruction

A i i l t d Assign implant code

Code the intent

Scope of Regional Lymph Nodes code 2, 6, or 7 when sentinel node

mentioned in the operative report and/or pathology report(s)and/or pathology report(s)

Use operative report as primary source

New Coding Instructions for 2012 cases

Do not code a hilar or mediastinal mass as primary unless stated as such

Clearly document radiology findingsClearly document radiology findingsMost often your best source for CS staging


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Mass, enlargement, or adenopathy in the hilum or mediastinum

Considered regional lymph node involvement

Understand clinically apparent vs. inapparent disease

H l d id if C d 150 i Helps you decide if Code 150 is correct for CS Extent

DRE does not mention a palpable tumor, mass or nodule

Negative imaging studies

MD statement of T1c


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Clinician documents “tumor”, “mass”, or “nodule” findings from DRE

Tumor is palpable or visible by imaging

Physical exam will be only source you can use to determine inapparent tumor vs. apparent tumorUnless the managing

clinician/urologist considers the imaging reliable for staging

To Code SSF6 (CRM), you must mention it in your text

Use code 999 if not mentioned in path or stated as “Margins, NOS”

Look for mesentery or radial termIf the CRM is involved (positive), use

code 000


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If right hemi-colectomy performed, do not automatically assign site code C18.2 (ascending colon)

Use your source priority rules here1. Surgeon’s statement2. Pathology report3. Imaging

CS Extension often miscoded

Avoid using the 400, nos code ( t i th h ll )(extensive through wall, nos)

Adipose tissue is considered connective tissue

Sigmoidectomy path report: invasive adenocarcinoma, poorly diff, involving pericolic p y , g padipose tissue, invades musclaris propria into serosal adipose tissue


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400 Extension through wall, NOSInvasion through muscularis propria or muscularis, NOSNon-peritonealized pericolic tissues Non peritonealized pericolic tissues invadedPerimuscular tissue invadedSubserosal tissue/(sub)serosal fat invadedTransmural, NOSWall, NOS T3 T3 L L

450 Extension to:All colon sites:

Adjacent tissue(s), NOSConnective tissueMesenteric fatMesentery MesocolonPericolic fat

500 Invasion of/through serosa (mesothelium)(visceral peritoneum) Tumor penetrates to surface of visceral peritoneump

Code 500 is the correct code for this case due to the statement: “..invades muscularis propria into serosal adipose tissue..”


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Multiple tumors should be coded to C67.9 and not C67.8

Pay attention to TURB findings to assign the best site code

MD doesn’t state primary site of origin

Consider clinical presentation

Consider histology type if biopsy performed

Abstracting is a challenge

Proper use of text is importantp p

Abstract one site at time

Use your site specific rules and guidelines in SEER Appendix C


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“If it wasn't hard, everyone would do it. It's

h h d h the hard that makes it great.”

Tom Hanks

Facility Oncology Registry Standards (FORDS): Revised for 2012

SEER Program Coding and Staging Manual 2012

SEER Appendix C – Site Specific Coding Modules

2012 NAACCR Volume II Version 13: Chapter X, Data Dictionary

Collaborative Staging, v.02.04, Parts I and II


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Editing Staff at Georgia Center for Cancer Statistics

Judy Andrews, CTRPh lli Wil CTRPhyllis Wilson, CTR

Documents

GATRA/GCCR Fall Conference 11/12/2012 November 14-16, 2012 … Abstracting Tips from the... · GATRA/GCCR Fall Conference November 14-16, 2012 11/12/2012 8 Before you assign 999,