From Abstract to Audit and Back Again Nancy Rold Missouri Cancer Registry MoSTRA Annual Meeting 2010 This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services (DHSS) (#U58/DP ) and a Surveillance Contract between DHSS and the University of Missouri.

To see ourselves as others see us, would from many a blunder free us. -Robert Burns

Outline Review Results ◦ National NPCR audit ◦ NPCR audit of MCR data ◦ MCR audits of hospital data Strategies to Use ◦ Field specific recommendations to avoid occasional traps and pitfalls

National NPCR Audit Compared select abstract data fields to source documents for all sites from 28 states Cases diagnosed Overall accuracy by state was % - Excellent!

NATIONAL NPCR AUDIT CS Elements Errors by Diagnosis Year Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis

NATIONAL NPCR AUDIT Surgery Errors by Diagnosis Year Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis

NPCR Audit of MCR Data In 2008, with the help of 9 Missouri hospitals of varying size - Thank you!! NPCR re-abstracted 297 MCR cases diagnosed in 2005 for Quality in 20 critical data fields Casefinding was also audited to assess data for Completeness

NPCR Audit of MCR Data Overall data accuracy for Missouri was 95% Overall completeness was 96.7%

NPCR Audit of MCR Data Accuracy Rates for Tumor-Specific Elements Source: NPCR Data Completeness and Quality Audit of Missouri Cancer Registry – Diagnosis Year 2005

NPCR Audit of MCR Data Sites with the highest error rates ◦ Lung 20% ◦ Breast 19% ◦ GI & Urinary15%

MCR Audits of Hospital Data MCR tries to audit every hospital within a 5 year cycle Audits may include casefinding and/or re-abstraction/re-coding Again, Thank You for participating!

MCR Re-Abstraction - Sources 2007 Hospital Data Abstracts From Recent Transmittal(s) Text - Source Document

MCR Re-Abstraction - Outcomes Primary Sites Breast - Highest Incidence of Errors (10%) Colorectal (8%) Lung (6%)

MCR Re-Abstraction - Outcomes Field Coding Errors CS Extension Highest Incidence of Errors (11%) Grade, CS LNs, Rx Surgery Summary (10% Respectively) Primary Site/Subsite, Dx Date (9% Respectively)

MCR Re-Abstraction - Recommendations Enter Supporting Text Into the Abstract First Then Code the Data Items Review Codes and Text Carefully to Ensure Each Substantiates the Other Be Specific When Assigning Codes Look Twice Before Assigning 9’s

MCR Re-Abstraction - Conclusion Text to Code Auditing will be one of MCR’s standard audit methods Keep in mind Supporting Text is required as explained in previously published MCR guidelines and now in the MCR Manual

MCR Casefinding Audit - Purpose Affirm Case Completeness of Electronic Reporting Facilities – 2007 data Special Emphasis on Evaluation of New Multiple Primary rules Evaluate Hospital Casefinding Procedures, Patterns Provide Education

MCR Casefinding Audit - Sources Twenty Facilities Reviewed - High, Medium, Low Categories 2007 MRDI Provided By Facility 2007 MCR Extract File Of Hospital Data

MCR Casefinding Audit - Outcomes Overall Results Were Very Good % Fifteen Hospitals Met the Standard 1 Hospital Was 100% Complete!! 2 Hospitals Missed Only One Case!

MCR Casefinding Audit - Findings Overall Case Completeness Facility Type Match Cases Missed Cases Matched & Missed Per Cent Complete All Total5, ,

Casefinding – Types of Missed Cases Clinically Diagnosed cases Cases Diagnosed On Imaging Cases Diagnosed on Biopsy Encounters for XRT, Chemotherapy, Hormonal Therapy Majority Outpatient Cases

Casefinding - Reasons for Missed Cases Pathology Reports / OP Treatment Summaries Not Routed to Registry No MRDI Review Inadequate MRDI Review Incomplete ICD-9 and Service Codes on MRDI

Casefinding - Recommendations Do Not Limit Casefinding to Pathology Reports or Treatment Summary Referrals Develop a Medical Record Disease Index Run Separate MRDI’s To Capture Benign Brain/CNS Cases and Op Rx Cases

Casefinding - Recommendations Be cognizant of timeliness/completeness reminders Notify MCR of late file submissions Encourage electronic casefinding enhancements when feasible

CS Extension - Colon Path: MD adenocarcinoma extending through the subserosa into the pericolic fat Code: 450 – Extension to pericolic fat Not: 400 – Subserosal fat invaded or 420 – Fat, NOS Source: CS Colon Schema

CS Extension - Bladder Path: Transitional cell carcinoma, non- invasive Code: 010- stated non-invasive Not localized, NOS

CS Extension - Prostate H&P: PSA elevated, DRE unremarkable, biopsy recommended & done, stated cT1 Code: 150 – tumor identified by needle biopsy, e.g. for elevated PSA, clinically inapparent Not 999 – extension unknown See CS schema notes – registrar should not infer whether tumor is apparent

CS – SSF 3 - Prostate Code based on first course prostatectomy or autopsy findings, not the clinical findings coded in CS Extn 970 – no prostatectomy (RT consult notes may confirm this) 960 – unknown if prostatectomy done Avoid use of 030 – Localized, NOS when a more specific code applies (230 - both lobes)

CS – SSF 3 - Prostate Path: Gleason 7 adenocarcinoma with extracapsular extension and positive margins Code: 480 – extracapsular extension and positive margins Not: 420 – unilateral extracapsular extension

CS Extension - Lung Radiologic evidence of Pleural Effusion was not properly coded as CS Extn 72 in several findings in the NPCR audit of MCR 2005 data. NOTE: in 2010 pleural effusion is coded in CS Mets at DX (codes 15-18) for lung primaries and in SSF1 for Pleura primaries. Read the CS coding notes carefully relative to your case.

CS Extension - Thyroid Path: two areas of papillary carcinoma in left thyroid lobe Code: Multiple foci confined to thyroid Not: 300 – local, NOS

CS Extension vs. Mets Op Note/Path: Lung cancer with direct extension into adjacent rib Med Onc note: surgeon found rib mets Code: CS Extn 730 – Adjacent rib Not: Mets at Dx 40 Text, Text, Text – to support

CS Lymph Nodes – Lung CT scan: mediastinal mass suspicious for LN involvement Code : 200 – Mediastinal, NOS Not: Unknown For other terms that constitute clinical diagnosis of LN, see CS Manual, part 1section 1, pg 23.

CS Mets 999 – Unknown may be an over-used code 000 should be used if the cancer is stated to be early stage and tx is for such Example: Localized lung cancer treated with surgery alone.

CS Mets For standard treatments by stage see: _gls/f_guidelines.asp

Site - Meninges MRI of brain – probable meningioma Site Code: C70.0 cerebral meninges Not: C71.0 cerebrum

Subsite - Breast On the NPCR audit of MCR data, breast accounted for 60% of the subsite discrepancies.

Subsite - Breast Used by permission: April Fritz, A Fritz and Associates, LLC

Subsite - Breast C50.8 Single tumor Overlaps contiguous subsites Point of origin unknown C50.9 Multiple tumors Origins in different subsites of one breast, or NOS Source: FORDS p. 107, ICD-O-3 p. 25

Subsite - Breast Use of C NOS may be a result of the lack of availability in the medical record. Source: MCR data extract, Use of C50.9 by class of case in abstracts as % of total breast sites. Class 0Class 1Class 2Class 3overall 17%15%24%60%20%

C MCR Data

Histology – Colon Polyps Path: adenocarcinoma within a tubulovillous adenoma Code: 8263 – Adenocarcinoma in a tubulovillous adenoma Not: 8140 – Adenocarcinoma, NOS

Histology - Colon Polyps

Histology - Thyroid Path for thyroid surgery: papillary carcinoma Code: 8260 – papillary carcinoma (C73.9) Not: 8050 – papillary carcinoma, NOS

Grade – Bladder (historic) Path: papillary urothelial carcinoma, low grade Code: 2 – moderately differentiated Not: 1 – well differentiated Similarly high grade was coded to 04 undifferentiated BUT….

Grade – Bladder – NEW! August I&R question 48073: For Urothelial Bladder Primaries, stated high or low grade: SSF 1 – records the grade (010 low, 020 high) Grade (6 TH digit) is coded 9 Grade Path System and Value = blank FORDS p. 115 bullet 4, other sections to be clarified in next update

Grade - Prostate Path: adenocarcinoma, Gleason 6 Code: 2- moderately differentiated Not: 9 – unknown Source: FORDS p. 12 WD Gleason 2,3,4 MD Gleason 5,6 PD Gleason 7-10

Grade – GI sites Path: liver biopsy – moderately differentiated adenocarcinoma, consistent with colon primary Code: 9 – grade of colon primary is unknown FORDS p. 112 Code the grade or differentiation from the pathologic examination of the primary tumor, not from metastatic sites.

Biopsy vs. Surgery Incisional Biopsy Op Note: breast core needle biopsy Code in Dx/Staging Procedure - 02 biopsy of primary site (a diagnostic procedure) Excisional Biopsy Op Note: excisional biopsy of breast mass Code in Surgery of Primary Site: 22 excisional biopsy (a treatment)

Surgery Code - Breast Op Note: L total Mastectomy, no reconstruction Code: 41 – Total Mastectomy WITHOUT removal of uninvolved contralateral breast Not: 40 – Total Mastectomy

Surgery Code – Mastectomy, NOS MCR Data on Mastectomy Rates

Surgery Code - Breast Op Note: R simple mastectomy and axillary LN dissection Code: 51 - Modified Radical Mastectomy Not: 41 - Simple Mastectomy Source: FORDS p. 270 – simple mastectomy does not include an axillary dissection

LN Surgery Code – Breast Op note: Three sentinel lymph nodes removed Code: 2 – Sentinel lymph node biopsy Not: LN removed Source: FORDS p. 225

LN Surgery Code - Breast Op Note: 5/1/ sentinel lymph nodes removed, pos 5/8/10 – axillary LN dissection, 2/5 LN pos Code: 7 – SLN and code 5, at different times Not: 5 – four or more regional LN removed Source: FORDS p. 225

Surgery Code and Date Op Notes: 4/5/10 Lumpectomy 5/7/10 Simple Mastectomy Code: Rx Date Surgery (First) & First Course = 4/5/10 Rx Summ Surgical Procedure of Primary Site = 41 Simple Mastectomy (see FORDS – code most invasive procedure)

Surgery Code and Date Op Notes: 4/5/10 Excisional biopsy 5/7/10 Re-excision to clear margins Code: Rx Summ Surgery of Primary Site – 23 – Re-excision

Surgery Code - Colon Colonoscopy Report: polypectomy performed Code: 28 - polypectomy, endoscopic Not: 26 – polypectomy, NOS Source: FORDS p. 255

Surgery Code – Rectal Op Note: polypectomy via electrocautery snare Code: 22 - polypectomy, electrocautery Not: 20 – local excision, or 26 – polypectomy (note: the highest code is not the most detailed) Source: FORDS p. 259

Surgery Code - Prostate H&P: TURP recommended for BPH (benign prostatic hyperplasia Path: incidental finding of prostate adenocarinoma in 5% of resected tissue Code: 22 – TURP – cancer is incidental finding during surgery for benign disease Not: 21 – TURP, NOS Source: FORDS p. 278

Surgery Code - Lymphoma CT scan – single suspicious supraclavicular node noted Op Note/Path – excised node contains lymphoma Code Surgery Primary Site - 25 Less than a full chain, includes excisional bx single LN

Date of First Course Therapy When there is a decision not to treat, Missouri follows the CoC rules. Code: the date the decision was made: 8/8/2010 Not blank, which is used only for autopsy only cases Source: FORDS p. 211