Radiation Hitting the Mark

Resources STandards for Oncology Registry Entry STORE 2018 www.facs.org/~/media/files/quality%20programs/cancer/ncdb/store_manual_2018.ashx CTR Guide to Coding Radiation Therapy Treatment in the STORE https://www.facs.org/-/media/files/quality- programs/cancer/ncdb/case_studies_coding_radiation_treatment.ashx

Resources CTR Guide to Coding Radiation Therapy Treatment in the STORE This document was prepared as a platform for “learning by example”. Gives clinical examples that will provide guidance for 95% or more of the clinical situations you will encounter. Provides a Summary of Coding Principles that clarifies misconceptions and misinterpretations within STORE 2018 CTR Guide to Coding Radiation Therapy Treatment in the STORE trumps the STORE 2018.

Radiation Hitting the Mark Uses the CTR Guide to Coding Radiation Therapy Treatment in the STORE in its approach and design. Addresses the more challenging principles. Allows you to learn by example. Gives rationale and references.

Case 1

Case 1 cont.

Case 1 cont.

Case 1 cont.

Case 1 cont. Rationale: #1: Code 3 in this field, Margins and LVI are stated thus, we know surgery was performed. #5: Code 20181120. Though page 1 states the date completed as 11/19/2018, page 2 states end date as 11/20/2018. #7: Code 01 (Radiation treatment completed). The “End of Treatment Summary” (pg #1) indicates that only 3/4 of the fractions were administered the “Treatment Summary” (pg #2) states 4/4 fractions were administered. It is important to remember that the reports you have may not give clear, concise or detailed information so you may have to piece together the puzzle from other reports that are available to you.

Case 1 cont. Rationale: #8: Code 005256. Add Total Phase 1 Dose (#15) and Total Phase 2 Dose (#22) = Total Dose (#8). Both used the same modality of External Beam Radiation Therapy (EBRT), though one was photons and the other was electrons. Also, both were to the same volume, though one was to the whole breast and one was to partial breast. (See: “CTR Guide to Coding Radiation Therapy Treatment in the STORE” page 6).

Case 1 cont.

Case 1 cont. #9: Code Volume to 40 (Whole Breast). FiF (Field-in-Field/forward planning) is treatment involving the whole breast. #10: Code 00. No nodes positive thus, there are no cancerous nodes that need to be treated. If nodes are “exposed” to radiation that does not mean they are being intentionally “targeted”. (See: “CTR Guide to Coding Radiation Therapy Treatment in the STORE” page 9).

Case 1 cont. #11: Radiation Energy listed with Megavolts (MV) or X = external beam, photons. #12: Code 05 (IMRT). Though FiF is usually 3-D, the summary states it is IMRT. Rules state that it “Should be clearly described as conformal or 3-D therapy”. (See: STORE 2018 page 288).

Case 1 cont.

Case 1 cont. #16: Code 41 for Volume (Breast - Partial). Phase 2 was a “boost” or “cone down” which delivers additional radiation to the region at the greatest risk for recurrence (i.e.: the surgical bed). #17: Code 00 (No radiation treatment to draining lymph nodes). Though in Phase 1, the regional lymph nodes were targeted and treated, phase 2 is a BOOST and with a BOOST the tumor/tumor bed is the primary target. Thus, in Phase 2 lymph nodes may be “exposed” to radiation but they are not being intentionally “targeted”.

Case 1 cont. #18: Radiation Energy listed with Electron (E or e-) = external beam, electrons. #20: Code 004. “Treatment Summary” states 4/4 fractions were administered. #22: Code 001000. “Treatment Summary” states 4/4 fractions were administered. 4 fractions x 250 dose per fraction = 1000 Total Phase 2 Dose .

Case 2

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Case 2 cont. Rationale: #1: Code 3 in this field, “Toxicities Summary” (pg 1) and “Special Points” (pg 2) refers to the prostate bed as area that received treatment. Prostate bed is a surgical reference to indicate a prostatectomy thus, we know surgery was performed

Case 2 cont.

Case 2 cont. Rationale: #9: Code 86 (Pelvis NOS). The prostate was removed during the prostatectomy thus, here is no prostate to target. Treatment will be targeted to the Pelvis NOS. NOTE: If the the prostatectomy was not preformed and the prostate remained intact, you would code Volume to 64 (Whole Prostate). Even if the report lists the treatment site as pelvis, the prostate is still the primary target. (See: “CTR Guide to Coding Radiation Therapy Treatment in the STORE” page 11).

Case 2 cont. #10: Code 06 (Pelvic lymph nodes). Toxicities Summary states radiation completed to the regional nodes. Thus, they are being intentionally “targeted”.

Case 2 cont.

Case 2 cont. #17: Code 00 (No radiation treatment to draining lymph nodes). Though in Phase 1, the regional lymph nodes were targeted and treated, phase 2 is a BOOST and with a BOOST the tumor/tumor bed is the primary target. Thus, in Phase 2 lymph nodes may be “exposed” to radiation but they are not being intentionally “targeted”.

Case 3

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Case 3 cont.

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Case 3 cont. Rationale: #1: Code 3 in this field. Summary states that a Total Abdominal Hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) was performed. #5: Code 20190422. The date on the summary for Phase 2 and 3 states 04/22/2019. #6: Code 03. Toxicities Summary states that HDR treatments with vaginal cylinder, followed 25 Gy of external beam. Phase 2 was mentioned in the text for phase 3 but no individual summary for this phase was included in the record.

Case 3 cont. #8: Code 012500. Phase 1 and 2 are to the same volume and use the same modality (EBRT), even though one modality is external beam NOS and the other is external beam photon. This field is recorded in centi- Gray (cGy), so pay close attention to each phases unit of measure (Gy ,cGy, cGe, etc).

Case 3 cont.

Case 3 cont. #9: Code Volume 86 (Pelvis NOS). The corpus uteri was removed during the TAH, there is no uterus to target. Treatment will be targeted to the Pelvis NOS. #10: Code 06 (Pelvic lymph nodes). Positive pelvic lymph nodes was excised thus, lymph nodes will be targeted for treatment.

Case 3 cont.

Case 3 cont. #16: Code 86 (Pelvis NOS). Phase 2 is a BOOST. #17: Code 00 (No radiation treatment to draining lymph nodes). BOOST treatment focuses on tumor bed. #18: Code 01. Summary just says “external beam”. #19: Code 01. Summary just says “external beam”. #21: Code 02500. Phase unit of measure is stated in Gy and you must convert to centi-Gray. 1 Gy=100 cGy thus, 25 Gy x 100 cGy = 2500 cGy .

Case 3 cont.

Case 3 cont. #23: Code to volume 72 (Vagina). Treatment delivered with brachytheraphy via a vaginal cylinder. #24: Code 00 (No radiation treatment to draining lymph nodes). Vagina is primary target. #25: Code 09 (Brachytheraphy, intracavitary, HDR). #26: Code 88 (Not Applicable). Treatment not by external beam. (See: “STORE 2018”, page 286)

Case 3 cont. #28: Code 99998 (Not applicable, radioisotopes administered to the patient). There is no agreed upon standard for documenting a dose by brachytherapy. (See: “CTR Guide to Coding Radiation Therapy Treatment in the STORE” page 6). #29. Code 999998 (Not applicable, radioisotopes administered to the patient). There is no agreed upon standard for documenting a dose by brachytherapy. (See: “CTR Guide to Coding Radiation Therapy Treatment in the STORE” page 6). NOTE: List phase in chronological order.

Take home points Compare ALL records to verify dates. Read the summaries to look for hidden phases or information. Determining if surgery was completed will help to identify the volume. If nodes are “exposed” to radiation that does not mean they are being intentionally “targeted”. They must be part of the treatment plan. Look for statement of positive lymph nodes. Total dose is a cumulative dose for the phases that were performed using the same modality (i.e. external beam, brachytherapy, etc.). If combining phases to calculate Total dose the phases must have been performed on the same volume.

Questions?

Contact Information: Shelly Gray 859-218-2101 sgray@kcr.uky.edu Tonya Brandenburg 859-218-3195 tbrand@kcr.uky.edu