Bladder, Kidney Parenchyma and Testis Education and Training Team Collaborative Stage Data Collection System Version 0203 CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Learning Objectives Understand rationale behind changes and updates Understand use of codes and reporting Determine proper code use for accurate reporting Understand finding specific documentation SSFs Coding rules CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Outline Overview of the following schemas: Bladder Kidney Parenchyma Testis Review Collaborative Stage data items for schemas Describe changes to schemas in CSv2 This presentation will cover the changes and some information on the following schemas: Bladder, Kidney Parenchyma and Testis. We will cover all the changes made in version 2, with focus on v0203 changes. We will then review of the data items for each schema. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder Histologies Papillary Transitional Cell Carcinomas (67.9%) Transitional Cell Carcinomas, NOS (25.0%) Carcinoma, NOS (1.5%) Squamous Cell Carcinoma, NOS (1%) Note: Many Bladder tumors have multiple histologies CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder AJCC 7th edition stage derived from: T (CS Extension) N (CS Lymph Nodes) M (CS Mets at Dx) Eval codes (for clinical/pathologic staging) No site specific factors or extra tables used for AJCC 7th edition staging AJCC 6th edition uses SSF 2 and extra tables due to changes in staging for lymph nodes Bladder is very straightforward when it comes to deriving AJCC stage. You need your CS Extension code, your CS Lymph Nodes code and your CS Mets at Dx code and the Eval codes to get a final stage. No SSF’s or extra tables are involved for 7th edition. For 6th edition, you need SSF #2 and extra tables to get the right N lymph node value. As long as your are coding lymph nodes and SSF #2, you should not have any difficulty getting the right AJCC 6th stage. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Extension-Notes Noninvasive papillary carcinomas Listing of definite statements Listing of inferred descriptions Extended Note 3 for in situ Extended Note 3 for locally invasive Expanded notes for coding extension Several notes moved around Notes rewritten to clarify instructions Notes were added regarding nonvasion for papillary transitional cell carcinomas. In this note, there is a listing for definitive statements of noninvasion and a list of inferred statements. Also included in expanded note 3, are guidelines for coding in situ tumors and those with minimal invasion. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Extension OBSOLETE Codes (Automatically converted) 200 (v0200): See code 240 400 (v0203): See code 430 410 (v0203): See code 411 415 (v0203): See code 411 420 (v0203): See code 421 450 (v0200): See code 810 This slide summarizes all the obsolete codes that are automatically converted. This is a summary from the major updates, from the original conversion and the v0203 conversion. Most of these changes were done to align the codes with the format that is being developed for all schemas. For example, code 200 had “stated as T2 [NOS]” added to it and then was placed at the end of the T2 codes. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Extension OBSOLETE Code 600 Extension to distal ureter divided into: Code 165: Subepithelial connective tissue of bladder and/or distal ureter Code 215: Superficial muscle of bladder and/or distal ureter Code 235: Deep muscle or extension through wall of bladder and/or distal ureter Code 245: Muscle (muscularis propria) invaded, NOS of bladder and/or distal ureter Code 630 Prostatic stroma; Prostate, Ureter (excluding distant ureter), NOS; Urethra Code 600, which included ureter, would have included all portions of the ureter. However, since distal ureter is now included within codes 165, 215, 235, and 245, if the ureter, other than the distal portion, is involved, it is coded to 630. It’s not how deep only in the ureter, but per note 7, if a tumor involves both the bladder and the distal ureter contiguously, extension is coded based on the deepest invasion of either organ. Example: Bladder tumor extends into the distal ureter with lamina propria invasion of bladder and in situ disease in the ureter would be coded 165. Code 630 is now for prostatic stroma, prostate and urethra. For this coding review, once you determine that you don’t have a case that involves the distal ureter, than you can default to code 630. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Extension OBSOLETE Codes 730/801 Code 730 divided into: Code 673: Rectum, male Code 710: Pubic bone Code 715: 700 (bladder is fixed) + 673 Code 720: (710 or 700) + 677 Code 801 divided into: Code 677: large intestine (includes rectum, female) Code 802: Further contiguous extension The next code is 730, which was rectum, male and pubic bone. These two have been separated and are now coded in 673 for rectum, male and 710 for pubic bone. Code 715 and code 720 are new combination codes. Code 801 is now divided into three codes, code 677, combination code 720 and then code 802, for further contiguous extension CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Lymph Nodes CS Lymph Node Common Iliac Nodes N1: single positive node N2: multiple positive nodes   N3: common iliac node involvement Common Iliac Nodes Coded in CS Lymph nodes for 7th edition Previously coded in CS Mets at Dx SUMMARY OF CHANGES    Nodal classification Common iliac nodes  were reclassified in AJCC 7th ed. as regional nodes and not as metastatic disease. N staging system change N1: single positive node in primary drainage regions N2: multiple positive nodes in primary drainage regions  N3: common iliac node involvement  Regional nodes include bilateral and contralateral involvement of named nodes. The reference to the size of the metastasis in the lymph node was removed from CS Lymph Nodes because size of the lymph nodes is not a factor of AJCC 7th edition N stage; however, side of nodes was moved to SSF 2 to maintain backward compatability and maintain the proper AJCC 6th edition N stage.   CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Lymph Nodes Code 150: SINGLE named regional nodes (N1) Code 250: MULTIPLE named regional nodes (N2) Code 350: Common iliac nodes/Stated as N3 Previously collected in CS Mets at Dx (code 10) Code 400: Code 350 + 150 (N3) Code 450: Code 350 + 250 (N3) Code 505: Regional Lymph Nodes NOS (N1) Code 800: Lymph Nodes, NOS (N1) The bladder lymph node codes are pretty straightforward. The key to assigning the correct lymph node code is to look at two factors: Do you have a single or multiple lymph nodes? Is your lymph node in regions listed in code 150 and 250, which are identical. The only difference between these two codes is a single vs multiple The major change to lymph nodes is the moving of common iliac nodes from mets at dx to lymph nodes. There are three codes now to capture common iliac nodes information. The difference between these codes is single (code 400) vs multiple nodes (code 450) (from codes 150 and 250) or unknown how many nodes (code 350) Code 505 is to be used when you have a statement like “regional nodes involved” but you don’t know which regional nodes or you don’t know if you have single or multiple nodes involved. Code 800 would be used when a statement such as “positive nodes” is documented with no indication which ones they are and you don’t know if it’s regional or distant lymph nodes. Both code 505 and 800 are assigned a N1, which is the lowest N category. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder CS Mets at Dx Code 10 OBSOLETE: Common Iliac nodes moved to lymph nodes (codes 350, 400, 450) Code 50 OBSOLETE: Combination code with code 10 Code 55: New combination code for distant lymph nodes (code 11) and distant mets (code 40) Code 60: New code Distant metastasis, NOS Stated as M1 with no other information on metastases The major changes to Bladder mets at dx have to do with moving the common iliac nodes over to lymph nodes. Code 10 was made obsolete since this was the common iliac nodes. Code 50 was also made obsolete since this was a combination code that included code 10. Code 55 is the new code for a combination of distant lymph nodes and distant mets Code 60 is also new and should be used if you have distant mets, but you don’t know what they are, or you have a record that documents a M1. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder Site-Specific Factors SSF1: WHO/ISUP Grade SSF2: Size of Metastasis in Lymph Node SSF3: Extranodal Extension There are three new Site-Specific factors for Bladder, which we will go over. Site-specific Factor 2 – This field will be used to code the size of the metastasis in the lymph node, not the size of the lymph node itself. If the size of the metastasis is not documented, code the size of the involved lymph node itself as documented pathologically or clinically with pathology taking priority. The size of any node(s) coded in CS Mets at DX should not be recorded in this field. Site-specific Factor 3 – This field will be used to record the presence or absence of extranodal extension whether assessed clinically or pathologically of any involved regional node(s) coded in the CS Lymph Nodes field. Extranodal extension in any nodes coded in CS Mets at DX should not be coded in this Site-Specific Factor. If nodes are involved but the clinical documentation and/or pathologic assessment does not indicate extranodal extension, assign code 010 (no extranodal extension documented on the available reports). CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder Site-Specific Factor 1: WHO/ISUP Grade Histologic grade is prognostic factor for cancers of lower urinary tract Higher grade means poorer outcome Source of information: pathology report Collected also for Kidney Renal Pelvis Reference: CS Manual, Part I, Section II, pg. 132 WHO/ISUP is the preferred grading system for Bladder cancers, and also Kidney Renal Pelvis. Grade is a prognostic factor for lower urinary tract. A higher grade means a poorer outcome. This information can usually be found on the pathology report CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 14

Bladder Site-Specific Factor 1: WHO/ISUP Grade 010 Low grade urothelial carcinoma 020 High grade urothelial carcinoma 987 Not applicable; morphology is NOT urothelial Histology is NOT 8120-8131 998 No histologic examination of primary site 999 Unknown, not documented in record Grade described as grade ii, grade III Grade described as well, mod or poor diff Site-specific Factor 1 - Grading: a low and high grade designation will replace the previous 4 grade system to match current World Health Organization/International Society of Urologic Pathology (WHO/ISUP) recommended grading system. If the term “low grade” or “high grade” is indicated as the grade for a urothelial primary, assume it is a WHO/ISUP grade. A code, 987, has been included to specify the morphology is NOT urothelial. This SSF is applicable for histologies 8120-8131 Code 999 use when you have a grade that is not described as low or high, but is documented as well, mod or poor diff or a grade is written out, such as grade ii or grade III. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder Site-Specific Factor 2: Size of metastases in lymph nodes Survival impacted by size of lymph nodes Applicable for clinical or pathologic Pathologic takes priority Source documents: Clinical (imaging, physical exam) Pathologic (pathology report) Collected for: Bladder, Kidney Parenchyma, Testis Size of mets in lymph nodes, is collected in many schemas, including head and neck sites and several other GU sites. Survival is impacted by the size of the LN’s. The greater the size, the lower the survival. This can be collected either clinically or pathologically, although pathologic does take priority. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 16

Bladder Site-Specific Factor 2: Size of Metastasis in Lymph Nodes 000 No regional lymph nodes involved 001-979 Code actual size in millimeter’s 980 Size of lymph node greater than 980 mm 990 Microscopic focus or foci, no size focus given 991-997 Range/size codes 999 Unknown For SSF #2, you are coding the size of the positive lymph nodes. So, if you have negative lymph nodes, you automatically would code 000. This SSF is coded for clinical or pathologic, so if you have only a clinical workup that shows positive lymph nodes and provides a size, then you can code that information here. If your size is described as focus or foci, or microscopic, use code 990. If you have positive lymph nodes but your are not given a size, then you must code 999. If you have no information on lymph nodes, you don’t know whether they are positive or negative, also code 999. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Bladder Site-Specific Factor 3: Extranodal Extension of Regional Lymph Nodes Survival impacted by extranodal extension Applicable for clinical or pathologic Pathologic takes priority Source documents: Clinical (imaging, physical exam) Pathologic (pathology report) Also collected for Kidney Parenchyma The last SSF for Bladder, which is also collected in Kidney Parenchyma, is for Extranodal extension of regional lymph nodes. Survival is impacted by extranodal extension. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 18

Bladder Site-Specific Factor 3: Extranodal Extension of Regional Lymph Nodes 000 No regional lymph nodes involved 010 Extranodal extension not present 020 Extranodal extension present 030 Regional nodes involved, unknown if extranodal extension 999 Unknown For SSF #2, you are coding the presence of extranodal extension. This is for regional lymph nodes only, do not code information about distant lymph nodes (coded in CS Mets at Dx) in this SSF. Use code 000 when lymph nodes are negative (remember: they have to be negative clinically and pathologically) Use code 010 when there is a definitive statement that ENE is not present, there is documentation that nodes are involved, but no mention of ENE, or the lymph nodes are described “clinically” as mobile Use code 020 pathology report states ENE is present, there is a clinical statement of ENE or the lymph nodes are described clinically as fixed or matted Use code 030 when there is a reference in the medical record that lymph nodes are involved, but there is no mention of ENE and you don’t know if they are clinically or pathologically positive Use code 999 when you don’t know if regional nodes are involved or there is no documentation in the record CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma Histologies Clear cell adenocarcinoma – 40.6% Renal cell carcinoma-34.0% Papillary adenocarcinoma-7.8% Renal cell carcinoma, chromophobe type-3.5% Other histologies-14.1% Note: Many Kidney Parenchyma tumors have multiple histologies CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma AJCC 7th edition stage derived from: T (CS Tumor Size and CS Extension) Extension Size Table used to determine T N (CS Lymph Nodes) M (CS Mets at Dx) Eval codes (for clinical/pathologic staging) No site specific factors used for AJCC 7th edition staging To stage Kidney Parenchyma cancers, you need 4 data items. For T, you need CS Extension ad CS Tumor Size. For tumors less than 10 cm with no other evidence of extension, T is based on CS Tumor Size. N and M are straightforward. No site-specific factors are involved in deriving stage for Kidney Parenchyma CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Tumor Size T2 divided into T2a and T2b “Stated as” codes for Tumor Size Code 994: Stated as T1a Code 995: Stated as T1b Code 996: Stated as T1 [NOS] Code 997: Stated as T2 [NOS] or T2a Code 998: Stated as T2b For tumor size, there are two main changes. The first main change is that T2 lesions have been divided into T2a (greater than 7 cm but less than or equal to 10 cm) and T2b (greater than 10 cm). The T1 and T2 categories are assigned based on tumor size; therefore an extra extension size table is used to assign the T category within the CS Algorithm. The second main change is that “Stated as” definitions have been added to the range codes 994-998. Remember, these should only be used when you have no other information on tumor size. If you use these codes, make sure that your extension codes match this as well CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Extension Notes Note 2: Gerota’s fascia Note 3: Invasion beyond the capsule Note 4: “In situ of renal parenchyma” Note 5: Use of code 300 Note 6: T1 and T2 tumors with tumor size Note 7: Direct extension to other structures For CSv2, 7 additional notes were added. There was one note in v0104, which is now Note 1. BRIEF description of each note………… CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Extension Ipsilateral adrenal involvement upstaged Reclassified as T4 for contiguous invasion Reclassified as M1 for non-contiguous invasion Renal vein involvement downstaged Reclassified as T3a “Stated as” Extension codes 310 (T1a), 320 (T1b), 330 (T1 [NOS]) 340 (T2a), 350 (T2b), 360 (T2 [NOS]) 605 (T3a), 610 (T3b), 620 (T3c), 625 (T3 [NOS]) 810 (T4) For CS Extension, - Ipsilateral adrenal involvement is reclassified as T4 if contiguous invasion, and M1 if not contiguous (This upstages adrenal involvement from T3a) Renal vein involvement is reclassified as T3a (This downstages renal vein involvement from T3b) New codes have been added in the CS Extension tables to allow coding from the physician’s assignment of a T value when the record does not specify the anatomic extension of the tumor. These are referred to as “stated as” codes, which were included in CSv1 for CS Lymph Nodes. The “stated as” codes are to be used ONLY when the physician’s staging is the only information available. If more specific information is available to support extension, it should be used to assign CS Extension. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Extension OBSOLETE Codes 390 (v0200): See code 625 400 (v0200): See codes 450 and 630 450 (v0203): See codes 460 and 660 600 (v0200): See codes 601 and 610 800 (v0203): See CS Extension codes 460, 601, 610-750, 801; CS Mets at Dx codes 20, 55 These are all the obsolete codes that are in Kidney extension. As you can see, some of these were made obsolete during the original release, and two of them were made obsolete with the v0203 release. You should not be using these codes. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Extension Code 450 Obsolete Data Reviewed in v0203 Cases reassigned to code 460 or 660 Code 460 Perirenal (perinephric) tissue fat; renal (Gerota’s) fascia, Renal sinus fat Code 660 Retroperitoneal soft tissue We will now look at the most recent extension codes that were made obsolete. For your cases that include these codes, you will need to do a manual review and reassign the appropriate code. Code 450 was made obsolete in version 0203. The reason for this was because retroperitoneal soft tissue was reassigned to a T4. Initially code 450 was split from code 400, where adrenal (suprarenal) gland, ipsilateral was separated out and assigned to a T4. After further review, it was determined that retroperitoneal soft tissue also needed to be a T4. The major difference between code 450 and 460 is that code 460 does not include retroperitoneal soft tissue. When you are reviewing these cases, only the cases that involve the retroperitoneal soft tissue go to code 660. The remaining cases will go to code 460. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Extension Code 800 Obsolete Data Reviewed in v0203 Cases reassigned to extension codes 460, 601, 610-750, 801 CS Mets at Dx 20, 55 Code 800 Further contiguous extension: Aorta Other direct extension Code 800, which is the other code obsoleted in v0203, also needs review and is a little more complex. Listed here is the original code 800. As you can see from the list of codes available, there are multiple places that these cases can go. We are not anticipating a large number of cases that need to be reviewed. The main reason for this change was to further define “direct extension.” This was due to Mets at Dx code 20 being added, which is extension to contralateral kidney/ureter, liver from left kidney and spleen from right kidney. Prior to Mets at code 20, there was no specific description of “other direct extension.” If you have direct extension to one of these, you will need to redefine your CS extension based on the remaining information you have for extension and use code 20 in mets at dx. If you do have direct extension to something else that is not mentioned in code 20 or 55 (which is a combination code that involves code 20), then you can use the new 801 code, which includes “other direct extension.” CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Lymph Nodes OBSOLETE codes Code 150 (v0203) See code 210 Code 400 (v0203) See codes 200 and 210 Code 200 MULTIPLE regional lymph nodes from code 100 Code 210 MULTIPLE regional lymph nodes from code 110, with or without nodes from code 100 Code 700: Regional lymph nodes, NOS Code 800: Lymph nodes, NOS The CS Lymph Node changes for Kidney are as follows: Nodal involvement is simplified to N0 and N1, removing the N2 category BUT all codes remain the same and the mapping has been adjusted accordingly. Regional nodes include unilateral, bilateral or contralateral involvement of nodes as specified in CS Lymph Node mapping Changes for v0203. Code 150 and 400, which are original v1 codes, were obsoleted and reworded to better describe the coding of lymph nodes. The new codes are 200 and 210 and for these, you are looking at multiple lymph nodes. For code 200, you have multiple lymph nodes for the regional lymph nodes listed in code 100. For code 210, you have multiple lymph nodes for the regional lymph nodes listed in code 110, with or without involvement of lymph nodes from code 100. Code 700 is used when you have regional node involvement, but don’t know which region, or you don’t know if you have single or multiple lymph nodes involved. Code 800 is when you have lymph node involvement, but you don’t know if it is regional or distant. When in doubt, default to the regional and use code 800. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma CS Mets at Dx-NEW Code 00: No distant mets Code 10: Distant lymph nodes Code 20: Extension to contralateral kidney Code 40: Non contiguous ipsilateral adrenal Code 50: OBSOLETED code Code 55: (40 or 20) + 10 Code 60: Distant metastasis, NOS Code 99: Unknown In version 1 of CS, Kidney Parenchyma used a general table for mets at dx, in other words, there were no codes specific to Kidney Parenchyma. For version 2, Kidney now has it’s own Mets at Dx table with metastatic codes specific to kidney. Codes 00 and 10 are common to most mets at dx table. Code 20 is for extension to contralateral kidney. So, if you have confirmation that a mass from one kidney has extended to the other, then you code 20. This was previously collected in CS Extension in code 800. Code 40 is for non contiguous involvement of the adrenal gland. Code 50 is obsoleted in version 0203 and has been replaced by code 55. The reason for this was to add code 20 to this combination code. Code 60 is for distant mets, NOS, when not knowing what the distant mets is. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma Site Specific Factors SSF1: Invasion Beyond Capsule SSF2: Vein Involvement SSF3: Ipsilateral Adrenal Gland Involvement SSF4: Sarcomatoid Features SSF5: Histologic Tumor Necrosis SSF6: Fuhrman Nuclear Grade SSF7: Size of Metastasis in Lymph Nodes SSF8: Extranodal Extension There are eight new Site-specific factors for Kidney. We have already discussed SSF 7 and SSF 8 in the Bladder schema and will not go over these in the Kidney Parenchyma schema. The code definitions are slightly different for Kidney Parenchyma, but the coding guidelines and purpose are the same. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Kidney Parenchyma Site-Specific Factor 1: Invasion beyond capsule Survival outcomes differ by location of involved extracapsular structures Information also collected in extension (T3) SSF provides more specificity on direction of invasion Source document: Pathology report SSF 1 is Invasion beyond capsule. It is collected in CS extension as an element of staging. Location of extension beyond the capsule may be an independent predictor of outcome therefore, it is also coded in SSF. The location of the tumor extension as stated in the pathology report is recorded in SSF 1. An example of a code and description for this field is code 010 which equates to Lateral invasion of the Perinephric fat. CS ext T3a, 3b and 3c include invasion of the renal sinus, venous invasion and inferior vena cava below the diaphragm. This field provides more specificity on the direction of the invasion Information to code this field would be found in the pathology report. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 31

Kidney Parenchyma Site-Specific Factor 1: Invasion beyond capsule Code 000: Not present/not identified Code 010: Lateral invasion Code 020: Medial invasion Code 030: 020 + 010 Code 991: Invasion beyond capsule, NOS Code 998: No surgical resection of primary site Code 999: Unknown Code 000 is used when there has been resection, the path report is available for review, and there is no invasion beyond the capsule. If there is no mention of invasion beyond capsule on a pathology report, assume none and code 000. Code 010-030 record the direction of the invasion, whether it’s lateral or medial or both Code 991 is for when invasion beyond the capsule is present but you don’t know the direction Code 998 is for no surgical resection of primary site or clinical diagnosis CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 32

Kidney Parenchyma Site-Specific Factor 2: Vein Involvement Survival outcome impacted by vein involvement Tumor cells disseminate easily in the bloodstream Information also collected in extension (T3) SSF provides more specificity on vein involvement Source document: Pathology report SSF 2 is information about venous involvement is coded in CS extension as a measure of stage. It is coded in CS SSF 2 as a prognostic factor. T3a, 3b and 3c all are coded due to venous involvement. SSF 2 provides information about specific veins that are involved include codes that combine more than one vein being involved. This allows for more specificity. Keep in mind this is for larger vein, not smaller unnamed veins that would be indicative of LVI. This information can be found in the pathology report. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 33

Kidney Parenchyma Site-Specific Factor 2: Vein Involvement Code 000: Not present/not identified Code 010: Involvement of renal vein only Code 020: Involvement of IVC below diaphragm Code 030: Involvement of IVC above diaphragm Code 040: Involvement of IVC, NOS only Code 050-090: Combination codes of 010-040 Code 998: No surgical resection of primary site Code 999: Unknown Code 000 is used when there has been resection, the path report is available for review, and there is no vein involvement. If there is no mention of vein involvement on a pathology report, assume none and code 000. For codes 010-090, you want to make sure that your extension codes match up. CS Extension code 601 states renal vein involvement NOS, while codes 610, 620 and 625 indicate involvement of the IVC. For example, if you coded CS Extension 610 for Inferior vena cava (IVC) below diaphragm, make sure that you code the same information in this SSF, which would be code 020. It is possible to have a higher extension code and still code renal involvement here. For example, you could have renal vein involvement along with extension to Gerota’s fascia. With this new SSF, you would be able to capture the information for the renal vein involvement in addition to the greater extension. Code 010 is for the renal vein only. Codes 020-040 are for the IVC, depending on if it’s below or above the diaphragm, or unknown Codes 050-090 are combination codes for 010-040 Code 998 is for no surgical resection of primary site or clinical diagnosis CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 34

Kidney Parenchyma Site-Specific Factor 3: Ipsilateral Adrenal Gland Involvement Involvement of ipsilateral adrenal gland (same side) is an adverse prognostic factor Contiguous involvement also coded in extension (Codes 630-645, map to T4) Noncontiguous involvement also coded in Mets at Dx (Code 40) Source document: Pathology report SSF 3 is information about contiguous ipsilateral adrenal gland involvement collected in this field and in CS Extension as it may impact prognosis. Noncontiguous ipsilateral involvement is captured in this field, and CS Mets at Dx code 40. The ipsilateral adrenal gland involvement, as indicated in the pathology report, should be recorded in SSF 3. An example of a code and description for this field is code 010 which equates to contiguous involvement of ipsilateral adrenal gland. Code 030 is used for contiguous and non-contiguous spread; in addition to a code for involvement and it is unknown if this is contiguous or noncontiguous spread. This would be documented in the pathology report. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 35

Kidney Parenchyma Site-Specific Factor 3: Ipsilateral Adrenal Gland Involvement Code 000: Not present/not identified Code 010: Contiguous involvement Code 020: Non contiguous involvement Code 030: 020 + 010 Code 040: Involvement of ipsilateral adrenal gland, not stated whether contiguous or noncontiguous Code 999: Unknown Code 000 is used when there has been resection, the path report is available for review, and there is no ipsilateral adrenal gland involvement. If there is no mention of ipsilateral adrenal gland involvement on a pathology report, assume none and code 000. For code 010, there is contiguous involvement. Remember, you want this to agree with your CS Extension code, which should be at least a 630. For code 020, there is non contiguous involvement. Remember, you want this to agree with your CS Mets at Dx code, which should be at least a 40. There is currently no code for “no surgery of primary site.” This will be corrected in the next version. If you have a clinical case where there is no surgery, code 999. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 36

Kidney Parenchyma: Site-Specific Factor 4: Sarcomatoid Features Sarcomatoid or spindle cell features are strong adverse prognostic factors Source documents: Pathology report SSF 4 is Sarcomatoid morphology which may be manifested by any renal cell carcinoma. The presence of sarcomatoid component in a renal cell carcinoma may be prognostically important. The presence of sarcomatoid features a specified anywhere in the pathology report should be recorded in SSF 4. An example of a code and description for this field is code 000 which equates to no sarcomatoid involvement; with the pathology reviewed and no mention of sarcomatoid features. This field is coded to 987 when the histology is not renal cell. If there is no pathologic review code this to 998. The pathology report is essential for completing this field. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 37

Kidney Parenchyma: Site-Specific Factor 4: Sarcomatoid Features Code 000: Not present/not identified Code 010: Present/identified Code 987: Not a renal cell carcinoma morphology Code 998: No pathologic exam of primary site Code 999: Unknown Code 000 is used when there is pathological information available for review, and there are no sarcomatoid features. If there is no mention of sarcomatoid features on a pathology report, assume none and code 000. Code 010 for when the pathology report indicates sarcomatoid features. Code 987 is for when you don’t have a renal cell carcinoma Code 998 is for when you do not have a pathologic exam (clinical/imaging only case) CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 38

Kidney Parenchyma Site-Specific Factor 5: Histologic Tumor Necrosis Necrosis indicates an aggressive tumor Outgrown blood supply An adverse prognostic factor for renal cell carcinoma Source document: Pathology report SSF 5 Tumor Necrosis is an independent predictor of outcome for renal cell carcinoma. The presence of tumor necrosis as specified anywhere in the pathology report should be recorded in SSF 5. An example of a code and description for this field is code 010 which equates to Histologic tumor necrosis present. Code 998 is used if there is no histologic exam of the primary site; assign 000 if there was review of the path report and necrosis is not mentioned. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 39

Kidney Parenchyma Site-Specific Factor 5: Histologic Tumor Necrosis Code 000: Not present/not identified Code 010: Present/identified Code 998: No pathologic exam of primary site Code 999: Unknown Code 000 is used when there is pathological information available for review, and there are no histologic tumor necrosis. If there is no mention of histologic tumor necrosis on a pathology report, assume none and code 000. Code 010 for when the pathology report indicates histologic tumor necrosis. Code 998 is for when you do not have a pathologic exam (clinical/imaging only case) CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 40

Kidney Parenchyma Site-Specific Factor 6: Fuhrman Nuclear Grade Nuclear grade of a kidney tumor, most important prognostic factor after tumor size Grade based on nuclear size and shape and prominence of nucleoli in the tumor cells Applies to renal cell carcinoma only Source document: Pathology Report SSF 6 is the Fuhrman grade and is based on a 4 grade system. It is based on nuclear size and shape, and the prominence of nucleoli and the presence of chromatin clumping in the highest grade. Record Fuhrman grade as specified anywhere in the pathology report in SSF 6 CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 41

Kidney Parenchyma Site-Specific Factor 6: Fuhrman Nuclear Grade Code 010: Grade 1 Code 020: Grade 2 Code 030: Grade 3 Code 040: Grade 4 Code 987: Not a renal cell carcinoma morphology Code 998: No histologic exam of primary site Code 999: Unknown Code 010 is equal to a Grade 1 and so forth to Grade 4. Code 987 when you have a non renal cell carcinoma morphology Code 998 when there is no histologic exam of primary site (clinical/imaging only) The remaining two SSF’s were covered in the bladder schema. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 42

Testis Histologies Germ cell tumors – 95% Seminoma Mixed germ cell tumors Embryonal carcinoma Choriocarcinoma and other germ cells Germ cell tumors, non seminomatous Teratomas Yolk sac tumors Sex cord/gonadal stromal tumors Note: Many Testis tumors have multiple histologies CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis AJCC 7th edition stage derived from: T (CS Extension, SSF 4: Radical Orchiectomy, Lymph vascular invasion) N (CS Lymph Nodes, Regional nodes positive, SSF 5: Size of mets in lymph nodes) M (CS Mets at Dx) S (SSF’s 13, 15, 16:Post orchiectomy Serum Tumor Markers ranges) Eval codes (for clinical/pathologic staging) Testis has one of the most complicated staging systems. There are multiple data fields involved. You need to understand how each of these data items contributes to the stage. That way, you’ll be able to better understand when you get errors. For T, there are 3 different data items. CS Extension, SSF 4 and LVI For N, there are also 3 different data items: CS Lymph nodes, Reg nodes pos and SSF 5, which is size of mets in lymph nodes. For M, you have just CS Mets at Dx. You also have a 4th factor in determining stage, and that is S. This is derived from SSF’s 13, 15 and 16. Then you also have the eval codes. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis CS Extension Codes 100 and 150 OBSOLETE Invasive tumor with/without vascular lymphatic invasion See code 160 Lymph vascular invasion collected in new data item Codes 400 and 450 OBSOLETE Epididymis involved with/without vascular lymphatic invasion See code 460 This slide summarizes the obsolete codes. There are 4 obsoleted codes in testis extension. The purpose for obsoleting these codes is because lymph vascular invasion is now collected in a new data item. Previous cases with these codes will be retained. For code 100, the tumor is confined to the body of the testis, rete testis or tunical albuginea without LVI, code 150 is confined to the body of the testis with LVI. Now, you code all cases confined to the body of the testis in code 160 and code LVI in a separate data item. For code 400, the tumor is confined to the epididymis without LVI, code 450 is confined to the epididymis with LVI. Now, you code all cases confined to the epididymis in code 460 and code LVI in a separate data item. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis and LVI Presence of LVI will increase the stage for T1 tumors Example: Tumor limited to testis and epididymis with no LVI would be a T1. Tumor limited to testis and epididymis with LVI would be a T2. Lymph vascular invasion, which is now a separate data item, is very important to the staging of Testicular cancers. For example, if you have a T1 tumor, the presence of LVI would upstage the tumor to a T2. T3 and T4 tumors are not affected by LVI, but you still need to collect the information for all cases. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis CS Extension “Stated as” codes added Code 320: Stated as T1 These are the four new codes added for “stated as” T values. Remember, only use these when you have no other information on how to code extension. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis CS Lymph Nodes Regional Lymph nodes “Stated as” codes added Codes 300, 350 and 400 Use only with previous scrotal or inguinal surgery Codes 500, 800 “Stated as” codes added Code 510: Stated as N1 Code 520: Stated as N2 Code 530: Stated as N3 Regional lymph nodes are collected in codes 100 and 200. For codes 300, 350 and 400, only use these codes when specified lymph nodes are involved (pelvic, external iliac and inguinal) and there is previous scrotal or inguinal surgery prior to the presentation of the testis tumor. Code 500 is for when there is documentation that states “regional lymph nodes” but there is no specification as to which ones there are. Code 800 is when there is lymph node involvement but you can’t determine if it’s regional or metastatic. This code will automatically derive a N1. Testis CS Lymph nodes has three new stated as codes for N1, N2 and N3. Once again, only use these stated as codes when you have no other information. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis: Deriving N CS Lymph Nodes Regional nodes positive SSF 5: Size of Metastasis in Lymph nodes Codes 010-030: Size of lymph nodes in three groups (less than 2 cm, 2-5 cm, greater than 5 cm) Code 999: Size of lymph not known, or unknown if regional nodes involved Lymph Node Eval Code Clinical eval: 0, 1, 5, 9 Pathologic eval: 2, 3, 6, 8 There are several data items that are used to derive N. The first is the CS lymph nodes, which are your regional lymph node involvement. The second is the number of positive lymph nodes, which is collected in regional nodes positive. The third is SSF 5, which is size of mets in lymph nodes. The coding of this field was covered in the Bladder schema. For Testis, this data field works the same way, although the codes have a slightly different description than that of Bladder. The difference between the codes is based on the size and the presence of extranodal extension. You have less than 2 cm, between 2 and 5 cm and greater than 5 cm. Also included in the codes is the presence of extranodal extension. For code 010, you have a lymph node size less than 2 cm with no extranodal extension. Code 020 is for a lymph node size of 2-5 cm OR extranodal extension. Code 030 is for a lymph node greater than 5 cm. Use code 999 when you don’t know the size of the lymph nodes or you don’t know if lymph nodes are positive or negative. When determining how to code this field, pathologic confirmation takes priority over clinical. The last data field is the eval code. There are two tables used that take into account the eval field. These are distinguished between clinical, which are codes 0, 1, 5 and 9 AND pathologic, which is 2, 3, 6 and 8. There is also a separate table for blank if you don’t collect this data item. As of 2010 though, all standard setters are collecting this data item, so it shouldn’t be blank. For cases coded prior to 2010, you may have a blank though. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis CS Mets at Dx Stated as codes Distant lymph nodes Code 30: New code, Stated as M1a Code 40: Stated as M1b added to definition Code 60: New code, Stated as M1 [NOS] Distant lymph nodes Collected in codes 11 and 12 If previous scrotal or inguinal surgery, use CS Lymph nodes to code lymph node involvement If unknown if previous scrotal or inguinal surgery, use CS Mets at Dx for distant lymph nodes For CS Mets at Dx, there are two new codes and one redefined. The stated as codes are code 30 (new), which is for M1a. Code 40, which was in v1, has been modified for stated as M1b. Code 60 (new), is for Stated as M1 [NOS] and for distant mets, NOS. (You know there are mets, but you don’t know where they are.) For distant lymph nodes (codes 11 and 12), you need to determine first if the patient has had previous scrotal or inguinal surgery. If so, code lymph node involvement in CS Lymph nodes. If you know there is no previous surgery, or don’t know, and you have distant lymph node involvement, then code that information in codes 11, 12 or 13. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis Site Specific Factors SSF1-SSF 3: OBSOLETE for CSv2 SSF4: Radical Orchiectomy Performed SSF5: Size of Metastasis in Lymph Nodes SSF 11: OBSOLETE for CSv0203 SSF’s 6, 7, 12, 13: AFP lab values/ranges SSF’s 8, 9, 14, 15: hCG lab values/ranges SSF’s 10, 16: LDH ranges Site Specific Factor’s for Testis are somewhat complicated, so I will be presenting them in groups. This will help you better understand how these SSF’s are related. For CSv2, SSF’s 1-3 are obsolete. The reason for deleting these was that the pre and post values were needed. For the initial SSF’s, it was not known if the values being recorded were for pre or post. SSF 11 is OBSOLETE for CSv0203. Initially this SSF was added in CSv0200 to capture the persistence of elevated tumor markers. After careful review, this SSF was deleted and the new post orchiectomy SSF’s were developed to record the information for each one. This was done so that the appropriate S stage (which is derived from 13, 15 and 16) could be derived. SSF 4 is for Radical Orchiectomy, which was briefly described in relation to deriving T SSF 5 is for Size of Mets in lymph nodes, which was briefly described in relation to deriving N The remaining SSF’s focus on the Serum Tumor Markers AFP, hCG and LDH. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis Site-Specific Factor’s: The Serum Tumor Markers Pre-orchiectomy Post-orhicectomy Value Range AFP 6 7 12 13 hCG 8 9 14 15 LDH n/a 10 16 This is a table that may help you understand the relationships between the SSF’s. When coding the SSF’s for Testis, you need to make sure that the codes for the related SSF’s match. For example, if you code test not done in one SSF but code an actual value/range in it’s counterpart, then you don’t have agreement between the two. The Range column on the right that is highlighted in red indicates the SSF’s that are needed to derive the S stage, which is needed to derive your AJCC stage. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis: SSF’s 6, 7,12 & 13 Alpha fetoprotein (AFP) Assess the patient’s metastatic tumor burden Useful in monitoring response to therapy A persistent elevated AFP indicates residual tumor Post-orchiectomy AFP used in the derivation of S Source documents: Clinical lab reports (blood or serum test), H&P, clinical statement in path report Now we will look at the actual serum tumor markers. The AFP, assesses the patient’s metastatic tumor burden. As with a persistent high PSA which may be indicative of residual or progressive disease, a high AFP may indicate residual disease. For SSF 6, you want to code the actual lab value, in SSF 7, you want to code the range prior to treatment, which is usually radical orchiectomy. For 12 and 13, you want to code the same information for Post orchiectomy. The purpose of recording all 4 SSF’s is to see if the AFP levels have dropped, which the expected/desired outcome. If you have no documentation for AFP levels, the best thing to do is code 999 unless you know your facility never does this testing. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0 53

Testis: SSF’s 8, 9, 14, 15 Human chorionic gonadotropin (hCG) Hormone produced by some germ cell tumors Presence of beta-hCG indicates malignancy Useful in monitoring response to therapy 5-8 days after orchiectomy, hCG should not be detectable Post-orchiectomy hCG used in the derivation of S Source documents: Clinical lab reports (blood or serum test), H&P, clinical statement in path report HCG is produced by some germ cell tumors and its presence always indicates a malignancy. It is used in conjunction with the AFP to help monitor the usefulness of therapy. Within 5-8 days or orchiectomy, an hCG level should not be detectable. For SSF 8, you want to code the actual lab value, in SSF 9, you want to code the range. For 14 and 15, you want to code the same information for Post Orchiectomy. The purpose of recording all 4 SSF’s is to see if the HCG levels have dropped to nothing, which is the expected desire/outcome. If you have no documentation for HCG levels, the best thing to do is code 999 unless you know your facility never does this testing. Your most common resource for these studies are your clinical lab reports, your H&P or a clinical statement in the pathology report. You may also need to f/u with your physician. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis Site-Specific Factor’s 10 & 16: Pre and Post Orchiectomy LDH Range Lactate dehydrogenase (LDH) This value is non-specific for testicular cancer Not routinely performed unless bulky disease evident Post-orchiectomy LDH used in the derivation of S Source documents: Clinical lab reports (blood or serum test), H&P, clinical statement in path report LDH is non specific for testicular cancer and is not routinely done unless there is bulky or distant disease. So, if you have a localized tumor, you may not have a LDH done. For SSF 10, you want to code the range. You do not have to record the actual lab value. For SSF 16, you want to code the same information for Post Orchiectomy. If you have no documentation for LDH levels, the best thing to do is code 999 unless you know your facility never does this testing. If you have a case that does not have an orchiectomy, or has neo-adjuvant therapy prior to the orchiectomy, code SSF 10 as 996 and code the LDH range in SSF 16. This is so this information can be captured for staging. Even though SSF 16 is based on surgical codes, you will stil lget a clinical stage with the right eval code. Your most common resource for these studies are your clinical lab reports, your H&P or a clinical statement in the pathology report. You may also need to f/u with your physician, especially for the post orchiectomy LDH. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis SSF’s 6 (AFP), 8 (hCG): Coding Structure (Pre-Orch Lab Value) Code Definition Use when: 000 0 nano/ milliliter Lab value is 0 001-200/250 Lab Values Lab value given 995 Pre-treated case (neoadjuvant therapy) Neoadjuvant therapy given before Rad Orch (pre-orch lab values coded in SSF’s 12, 14) Code TS Ext/Eval code as 5 or 6 996 No orchiectomy performed No orchiectomy performed (pre-orch lab values coded in SSF’s 12, 14) Code SSF 4 as 000 (No Rad Orch) 997 Test ordered, results not in chart Example: Lab value noted to be “wnl” or “elevated” but value not given 998 Test not done Facility/doctor’s office did not perform test 999 Unknown, not documented No documentation in record Since the coding structures are set up the same way for the serum tumor markers, I will be presenting them this way. This will help you to understand more fully how the SSF’s are coded. The first is for the pre-orchiectomy lab values for AFP and hCG. Remember, the lab values are not collected for LDH. Code 000 is for when you have an actual value of 0. Code 001-200/250 code the actual values. The APF goes up to 200, while the HCG goes to 250. These are done in code groups. Code 995 is for when you have a case that is treated with neoadjuvant therapy, usually chemotherapy. When you use code 995, you will code the pre-orchiectomy value in SSF’s 12 and 14. Also, when you use code 995, you need to use the appropriate eval code, which would be 5 or 6, which shows that you had neoadjuvant therapy. Code 996 is used when you have a case that does not have an orchiectomy. This is rare, but you are to use this code when it happens. You will code the pre-orhiectomy value in SSF’s 12 and 14. When you use code 996, make sure that SSF 4 is coded to 000, which is no radical orchiectomy performed. Code 997 is for when test is ordered and results are not in chart. For example, if you have a statement that the pre-orch lab value is “wnl”, but no numerical value available, use code 997. Code 998, test not done, should only be used when you know the test is not done. If there is no documentation in the record, do not assume that the test was not done. Remember, you may need to follow up with the physician to get the values for they may have been in the doctor’s office and not the hospital. When in doubt if the test was done, always default to 999. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis SSF’s 7 (AFP), 9 (hCG), 10 (LDH): Coding Structure (Pre-Orch Range) Code Definition Use when: 000 Within normal limits Lab value available and is “WNL” 010-030 Ranges Code the appropriate range 991 Pre-orchiectomy stated as elevated Lab value not available, but stated to be “WNL” 992 Pre-orchiectomy unknown, Serum Tumor Markers “WNL” Lab values not available for ALL Serum Tumor Markers, but stated to be “WNL” (code 7, 9 and 10 as 992) 993 Pre-orchiectomy unknown, Serum Tumor Markers “elevated” Lab values not available for ALL Serum Tumor Markers, but stated to be elevated (code 7, 9 and 10 as 993) SSF’s 7, 9 and 10, which are for AFP, hCG and LDH, the coding structures are set up the same way. Code 000 is for within normal limits. Use this code when the value is available and is wnl. You can get this information from the physician’s statement or the lab reference range provided on your lab report Code 010-030 code the range. The ranges are different for each of the SSF’s, so pay attention to the ranges for each one. Code 991 is similar to code 000, but you use this code when you don’t have the actual value available. If you use this code, then the SSF that looks at the value should be coded as test done, results not in chart. In this situation, you may have documentation that the pre orch value is elevated, but no other information. Code 992 is when there is a general statement of “serum tumor markers” are normal. In this situation, you would want to code 992 for 7, 9 and 10. Only use this code when the statement is referenced to all the tumor markers. Code 993 is the same as 992, but is for when all serum tumor markers are elevated. Once again, if you use this code, it should be coded the same in 7, 9 and 10 CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis SSF’s 7 (AFP), 9 (hCG), 10 (LDH): Coding Structure (Pre-Orch Range, cont.) Code Definition Use when: 995 Pre-treated case (neoadjuvant therapy) Neoadjuvant therapy given before surgery (code pre-orch range in SSF’s 13, 15, 16) 996 No orchiectomy performed No orchiectomy done (code pre-orch range in SSF’s 13, 15, 16) 997 Test ordered, results not in chart Test done, results not available, or lab value provided, but interpretation not available 998 Test not done Facility or doctor’s office did not perform test 999 Unknown, not documented No documentation in record Code 995 is for when you have a case that is treated with neoadjuvant therapy, usually chemotherapy. When you use code 995, you will code the pre-orchiectomy range in SSF’s 13, 15 and 16. Code 996 is used when you have a case that does not have an orchiectomy. This is rare, but you use this code when it happens. You will code the pre-orhiectomy range in SSF’s 13, 15 and 16. Code 997 is for when test is ordered and results are not in chart. If you use this code, make sure the corresponding SSF is coded the same way. Remember, if you have the statement that a serum tumor marker is elevated but you don’t have the actual lab value or range, you use code 991. Code 998, test not done, should only be used when you know the test is not done. If there is no documentation in the record, do not assume that the test was not done. Remember, you may need to follow up with the physician to get the values for they may have been in the doctor’s office and not the hospital. If you code test not done in 6 or 8, then you need to code test not done in these SSF’s as well. When in doubt if the test was done, always default to 999. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis SSF’s 12 (AFP), 14 (hCG): Coding Structure (Post-Orch Lab Value) Code Definition Use when: 000 0 nanograms/milliliter Lab value is 0 001-250 Lab Values Lab value given 997 Test ordered, results not in chart Example: Lab value noted to be “wnl” or “elevated” value not given 998 Test not done Facility/doctor’s office did not perform test 999 Unknown, not documented No documentation in record Now we are looking at the post orchiectomy SSF’s. The coding structures are very similar to the pre-orchiectomy SSF’s, especially for the lab values. So, here you have the lab values given. As with the pre-orchiectomy lab values, there is no LDH lab value for post-orchiectomy. Code 000 is for when you have an actual value of 0. Code 001-250 code the actual values. These are done in code groups. Code 997 is for when test is ordered and results are not in chart. For example, if you have a statement that the pre-orch lab value is “wnl”, but no numerical value available, use code 997. Code 998, test not done, should only be used when you know the test is not done. If there is no documentation in the record, do not assume that the test was not done. Remember, you may need to follow up with the physician to get the values for they may have been in the doctor’s office and not the hospital. When in doubt if the test was done, always default to 999. Also, last comment: When there is no orchiectomy or neoadjuvant therapy, code the pre-orchiectomy lab values in these SSF’s. Remember: For cases with no Radical Orchiectomy or nedoadjuvant therapy, code the pre-orchiectomy lab values in SSF’s 12 and 14 CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis SSF’s 13 (AFP), 15 (hCG), 16 (LDH): Coding Structure (Post-Orch Range) Code Definition Use when: 000 Within normal limits Lab value available and is WNL 010-030 Ranges Code the appropriate range 990 Post-orch unk, but pre-orch value “WNL” Code when post-orch value unk, pre-orch WNL (Code 000) 991 Post-orch stated as still elevated Code when pre-orch value elevated, post-orch value is still elevated 992 Post-orch unknown, Serum Tumor Markers “WNL” Lab values not available for ALL Serum Tumor Markers, but stated to be WNL (code 13, 15, 16 as 992) 993 Post-orch unknown, Serum Tumor Markers “elevated” Stated as Stage IS Lab values not available for ALL Serum Tumor Markers, but stated to be elevated (code 7, 8, 10 as 993) We are now looking at the three SSF’s that are used to derive the S stage, which is needed to derive the AJCC stage. Code 000 is for within normal limits. Use this code when the value is available and is wnl. Codes 010-030 code the range. The ranges are different for each of the SSF’s, so pay attention to the ranges for each one. Code 991 is for when your pre-orch value is elevated (whether indicated by the actual lab value and range, or by code 991 in SSF’s 7, 9 and 10) and your post orch is still elevated, but there is no lab value provided. Code 992 is when there is a general statement of “serum tumor markers” are normal for post orch. In this situation, you would want to code 992 for 13, 15 and 16. Only use this code when the statement is referenced to all the tumor markers. Code 993 is the same as 992, but is for when all “serum tumor markers” are elevated. Once again, if you use this code, it should be coded the same in 13, 15 and 16. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis SSF’s 13 (AFP), 15 (hCG), 16 (LDH): Coding Structure (Pre-Orch Range, cont.) Code Definition Use when: 997 Test ordered, results not in chart Test done, results not available, or lab value provided, but interpretation not available 998 Test not done Facility or doctor’s office did not perform test 999 Unknown, not documented No documentation in record Code 997 is for when test is ordered and results are not in chart. If you use this code, make sure the corresponding SSF is coded the same way. Remember, if you have the statement that a serum tumor marker is elevated but you don’t have the actual lab value or range, you use code 991. Code 998, test not done, should only be used when you know the test is not done. If there is no documentation in the record, do not assume that the test was not done. Remember, you may need to follow up with the physician to get the values for they may have been in the doctor’s office and not the hospital. If you code test not done in 7, 9 or 10, then you need to code test not done in these SSF’s as well. When in doubt if the test was done, always default to 999. Also, last comment: When there is no orchiectomy or neoadjuvant therapy, code the pre-orchiectomy ranges in these SSF’s. Remember: For cases with no Radical Orchiectomy or nedoadjuvant therapy, code the pre-orchiectomy ranges in SSF’s 13, 15 and 16 CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis: The S component of staging Serum Tumor Markers S0 S1 S2 S3 AFP 0-40 <1,000 1,000-10,000 >10,000 hCG < 0.8 (M) <5,000 5,000-50,000 >50,000 LDH 105-333 <1.5N 1.5N-10N >10N Based on post-orchiectomy ranges (SSF’s 13, 15 and 16) and before 2nd line of treatment (if needed) Tumor markers should decrease after radical orchiectomy Peristence of elevated tumor levels indicate presence of tumor, which may result in 2nd course of treatment The whole purpose of SSF’s 6-16 (not including SSF 11) are to get to this final table, computing the S stage. The S stage, which is part of the T, N and M staging for Testis, is evaluated based on the actual ranges put in for SSF’s 13, 15 and 16. The tumor markers should decrease after a radical orchiectomy. Persistence of tumor markers indicate the presence of disease and a second line of treatment may be started. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

Testis: Coding the Serum Tumor Markers when no Radical Orchiectomy Determining S stage when no orchiectomy Code the pre-orchiectomy levels (initial serum tumor marker range) in these SSF’s In the pre-orchiectomy SSF’s, code 996 Example: Initial hCG value is 9,200 ng/ml No orchiectomy done due to comorbidities (SSF 4=000) SSF 6 (Pre-Orchiectomy AFPLab Value) : 996 SSF 7 (Pre-Orchiectomy AFP Range): 996 SSF 12 (Post-Orchiectomy AFP Lab Value): 190 SSF 13 (Post-Orchiectomy AFP Range): 020 Several people are confused about the no orchiectomy cases and how to code the tumor marker SSF’s, so I have provided an example. In this example, we are using the AFP value, but the same process is used for hCG and LDH. Remember that LDH only has range SSF’s, no lab value SSF’s. For this case our initial AFP value is 9,200 ng/ml. We know there is no orchiectomy. For SSF 6, which records pre orch lab value, we code 996 and for SSF 8, for pre orch range, we also code 996. The 996 code tells us that no orchiectomy was performed and the initial AFP lab value and range are recorded in the post orchiectomy fields For SSF 12, we code the pre orchiectomy level of 9, 200, which is code 190 for the range 9,000-9,999 ng/ml For SSF 13, we code the pre orchiectomy range 2, which is code 020, which is 1,000-10,000 ng/ml . Then SSF 13 will be used to derive the S stage. You follow this same process for hCG and LDH. The reason this is set up this way is to simplify determining the stage for S. CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0

CAnswer Forum Submit questions to CS Forum Located within the CAnswer Forum Provides information for all Allows tracking for educational purposes Includes archives of Inquiry & Response System CS Forum: http://cancerbulletin.facs.org/forums/ CS Web Site: www.cancerstaging.org/cstage CSv2 Bladder, Kidney & Testis June 2011 Lecture Version: 1.0