Part 1 Section 1 Coding Instructions Education and Training Team

Part 1 Section 1 Coding Instructions Education and Training Team
Version 2 Overview and Update CSv0202 to CSv0203 Part 1 Section 1 Coding Instructions CS version 2 Education and Training Team CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

What We’ll Cover Rules changes and revisions Sites with Major Changes
CSv0202 to CSv0203 Sites with Major Changes Esophagus and Stomach Biliary Tract Peritoneum The focus of this session is a review of changes and revisions between CS version 0202 and We will also review a few sites that have significant differences requiring schema discriminators—esophagus, stomach and gastroesophageal junction, biliary tract, and peritoneum. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CSv2 Changes New name Collaborative Stage Data Collection System (CS) Commitment to make staging more clinically relevant Better definitions and instructions More site-specific factors As you know by now, CS has a new formal name that clarifies and emphasizes that this is a data collection system, not a new staging system. The system is still called CS for short. The AJCC Cancer Staging Manual and CSv2 made a commitment to make staging more relevant for clinicians and registrars by adding better definitions and instructions as well as including more prognostic indicators to the anatomic staging framework of previous editions. More site-specific factors were added to accommodate the relevant information. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CSv0203 Changes Based on post-publication changes in AJCC Cancer Staging Manual, seventh edition Continued work to make CAP Protocols compatible with registrar abstracting needs Thorough, independent review of codes and format by Data Validation Team There were a few post-publication changes in the AJCC Cancer Staging Manual seventh edition, notably a change in how the testicular tumor markers should be coded. These were published as an errata document in August The review team made sure that any changes in TNM seventh edition were incorporated into CS version 0203. Work continues to make the College of American Pathologists cancer protocols and checklists compatible with the information captured on the cancer registry abstract. The CAP Pathology Electronic Reporting Taskforce (PERT) includes several Certified Tumor Registrars knowledgeable about CS. A set of updated CAP protocols was released on the CAP.org website on February 1, 2011. After the release of CS version 0202, the CS leadership organized a Data Validation Team to thoroughly review the code structures and format of the CS schemas for consistency. Most of the changes in CS version 0203 are the result of this effort. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

2010 CSv2 Data Validation Project
March – August, 2010 Purpose Improve CSv2 system for registry use Validate mapping between CSv2 codes and AJCC and SEER summary staging systems Review every table of every schema Apply style criteria consistently across all schema tables Correct problems noted with first release of CSv2 The CSv2 Data Validation Project ran for six months during Every code, every table, and every schema was reviewed for consistency of phrasing and logical order by an independent group of CTRs familiar with CS. The proposed changes were reviewed by the original mapping team and if accepted were added to CSv This resulted in a number of new OBSOLETE codes in CS for 2011, a new conversion program, and the need for registrars to review a few cases and manually recode them. Problems identified in CS version 0202 were also corrected.

Results of Data Validation Project
Changes in CSv0203 Code 988 Not applicable clarified New and expanded table notes Code structures and definitions more consistent Formatting and punctuation Corrections to fix problems identified Missing code definitions T, N, M and stage group mapping More combination codes and converted codes Review of schema index page You will see these results of the Data Validation Project in CS version 0203 which takes effect for cases diagnosed in 2011. New definitions for code 988 were added to clarify meaning of “not applicable” both in original CSv1 site specific factors and those added in CSv2. New and revised table notes in numerous schemas expand clinical information and coding instructions As mentioned, code structures and definitions of similar codes across schemas were made more consistent, including improvements in formatting and punctuation Correction of obvious problems with code definitions and references to codes, for example adding a code to indicate that there was no histologic examination of a specimen when the data field asked for pathologic information Correction of TNM and stage group mapping in seventh edition, and a few from sixth edition and CSv1 More combination codes, obsolete codes, and converted codes Review of the information on schema index page, such as the histology code range, acceptable ICD-O topography codes, and a few revisions to data item names.

Results of Data Validation Project
Changes in CSv0203, continued New schema for plasma cell malignancies Updated schema for Kaposi sarcoma Post-orchiectomy tumor markers for testis added Newly required site-specific factor for intrahepatic bile duct Extensive revision of lung, GIST, cutaneous melanoma and corpus uteri extension tables In addition to the cosmetic changes and clarifications to wording, CSv0203 includes A new schema for multiple myeloma and other plasma cell malignancies A revised Kaposi sarcoma schema with additional site-specific factors New site-specific factors to collect post-orchiectomy tumor markers for testis A newly required site-specific factor for staging of intrahepatic bile duct cancers Significant changes in CS Extension tables for lung, GIST schemas, melanoma of skin, and corpus uteri

Example Colon CS Extension CSv0202
Code TNM7 Map TNM6 Map SS77 Map SS2000 Map 420 Fat, NOS T3 RE 450 Extension to: All colon sites: Adjacent tissue(s), NOS Connective tissue Mesenteric fat … Ascending and descending colon Retroperitoneal fat Transverse colon/flexures Gastrocolic ligament Greater omentum 460 Adherent to other organs or structures, but no microscopic tumor found in adhesion(s) 500 Invasion of/through serosa (mesothelium) (visceral peritoneum) T4a T4 550 Any of [(420) to (450)] + (500) 560 Stated as T4a, no other information 570 Adherent to other organs or structures, NOS T4b This is a section of the CS extension field for colon as it was in CS version Remember that CSv1 codes were expanded by adding a zero at the end. For example, CSv1 code 45 is now This expansion allowed more space to insert codes made necessary by the changes in the seventh edition of the AJCC Cancer Staging Manual. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Example Colon CS Extension CSv0203
Code TNM7 Map TNM6 Map SS77 Map SS2000 Map 450 Extension to: All colon sites: Adjacent tissue(s), NOS Connective tissue Mesenteric fat … Ascending and descending colon Retroperitoneal fat [truncated] T3 RE 458 Fat, NOS (was 420) 460 OBSOLETE–See Note 3, codes 565 and 570 470 Stated as T3, no other information 500 Invasion of/through serosa (mesothelium) (visceral peritoneum) T4a T4 550 500 + ( ) 560 Stated as T4a, no other information 565 Adherent to other organs or structures clinically, no microscopic examination… T4b 570 Adherent to other organs or structures, NOS The items in yellow show the changes to the same range of codes in CS version Code 420 was changed to 458, 460 was made obsolete and split into 565 and 570, and other modifications were made based on these changes. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

New Standards Setter Requirements
COC – minor changes SEER – same as COC NPCR – new requirements Data items needed to derive TNM7 stage (as available) CS Reg Nodes Eval, Mets Eval CNS SSF1 Breast SSF 15,16 Schema discriminators Effective with 2011 cases, the National Program of Cancer Registries requires the collection of CSv2 data items needed to derive Summary Stage, and certain breast and CNS site-specific factors not previously required. These include the breast HER2 summary result of testing and site-specific factor 16 that identifies “triple positive” and “triple negative” breast cancers. Many other site-specific factors are now listed as “required as available” to derive TNM seventh edition.

Reportability Issues Reportable-by-Agreement Cases
Staging systems available in TNM for neoplasms that may not be reportable to population-based registries Examples Borderline tumors of ovary GIST, NOS Carcinoid of appendix Squamous ca of skin High grade dysplasia (esophagus) PanIN III of pancreas, severe ductal dysplasia A number of questions have arisen since the publication of both the AJCC Cancer Staging Manual 7th edition and CSv2 regarding whether certain histologies and behaviors are reportable. In particular, the questions arise regarding gastrointestinal stromal tumors and newer terminology that was formerly called carcinoma in situ, but the issue applies to all types of malignancies. The AJCC Cancer Staging Manual 7th edition provides staging systems for a variety of tumors that clinicians see in their practices but which are not reportable to population-based registries, either because the default ICD-O code is not /2 or /3, or because the terminology is not included in state or provincial cancer reporting laws. Examples include pancreatic intraglandular neoplasia and high grade dysplasia of the esophagus, which have replaced carcinoma in situ of these organs as the preferred terminology of gastrointestinal and endocrine pathologists. Gastrointestinal stromal tumor, or GIST, has a spectrum of behaviors from benign to malignant, and the pathologist’s criteria for determining whether a GIST tumor is malignant are rather subjective. In ICD-O, the default code for an unspecified GIST is /1 or borderline behavior. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Reportability Issues, continued
The presence of a schema in CSv2 does not imply that the disease is reportable Follow instructions of population-based registry regarding reportability If reportable, follow instructions in schema If not reportable, follow facility policies for collecting data The AJCC does not define whether a case is reportable or not, but does provide staging systems for clinicians who see these types of cases. It is important to follow the reportability instructions of your population-based registry and the national standards setters. Do not assume that a case is reportable just because there is a staging schema for it in CSv2. If the case is not reportable to your population-based registry, discuss such cases with the cancer committee to determine whether they should be included in the facility registry as reportable-by-agreement. In either situation, be consistent—either include all cases of that type or exclude them from the registry. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS Coding Instructions Part I
Section 1 General rules Data fields rules More examples with rules Section 2 – Site-specific notes Lymph nodes (head and neck, breast) Other problematic data items Clinical status of regional lymph nodes (stomach, colon) Lab values and tumor markers Other site-specific factors The documentation for CS version 0203 is in three pieces. Part I is the CS Coding Instructions, which are divided into two sections. Section 1 is the coding rules themselves, both the general rules of CS and the rules that apply to individual data fields. Section 2 is a greatly expanded section that includes information about site-specific issues, such as the lymph node data items for head and neck and breast, clarification of other problem areas, and detailed information on lab values, tumor markers, and other site-specific factors. Both Section 1 and Section 2 have been extensively revised and updated between CS version 0202 and Changes in Section 1, the general rules, are marked with change bars in the left margin of the page. Section 2 has been extensively bookmarked to make the site-specific factor coding guidelines easier to find. Part II, the schemas themselves, are grouped by site code. More on that in a moment. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS Coding Instructions
Electronic document Designed for desktop use so it can be easily accessed PDF will allow sticky notes, word search, cross-referencing Part II schemas organized in site-related groups The CSv2 coding instructions have been designed to be used as an electronic document. Both the Part I documents (coding instructions and site-specific supplement) and Part II schemas are available at cancerstaging.org/cstage. The CSv2 coding instructions are in portable document format (PDF) and can be used with the free Adobe Reader. You should download them to your computer; once downloaded, there is no need to be online when you use the documents. The schemas are organized into groups, such as kidney and urinary tract, upper GI, and so forth so that you don’t need to have a large PDF containing all the schemas open. You can also access individual schemas and data items online. Using the electronic document is strongly recommended. If you were to print out all the schemas and the coding instructions in Part I, a paper manual would be over 3000 pages long. The documents allow you to do word searches and to add sticky notes, underlining, and highlighting to the pages and save them to your desk top. You can even export sticky notes from one version of a document and import them into a newer version, although there are some limitations to this process. CS version 0203 has also been extensively hyperlinked so that you can click on a data field in Part II and the text from Part I will be displayed for your review. Then you can click the “previous view” and return to the Part II document. Features in the electronic documents, such as search, hyperlinking, and cross-referencing will not work in printed documents Because of the document size, Part II schemas are organized by ICD-O site code. The exception is for the uncommon and infrequently used melanomas of the head and neck, which have their own files separate from the carcinomas of the head and neck. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Rules Review The remainder of this presentation will discuss some ongoing issues that have been identified in registrar understanding of how CS version 2 works. There were no changes to the general rules in Part I between CS versions 0202 and 0203, but a number of examples and more discussion was added to the documentation for version 0203. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS General Guidelines Timing rule Timing rule NOT identical to TNM7.
Includes all information gathered through completion of surgery(ies) in first course of treatment OR within four months of diagnosis in absence of disease progression whichever is LONGER. Timing rule NOT identical to TNM7. In the upper right corner of this series of slides is a number that refers to the page number in the Coding Instructions. On this slide, I-14 refers to Part I section 1, page 14, where the timing rule is discussed. One item that has not changed is the CS timing rule. Information can be gathered from diagnostic and therapeutic procedures through the completion of surgeries in the first course of treatment or within four months of diagnosis as long as there has been no disease progression—whichever is longer. Note, however, that the CS timing rule is no longer identical to TNM 7th edition. The difference is that for clinical staging in TNM, the timing rule is whichever is SHORTER of information obtained prior to initiation of any treatment or within 4 months of diagnosis, with no disease progression. CS remains the same as the timing rule for TNM pathologic staging. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS General Guidelines Clinician statement of T, N, M
Codes included in CS version 2 Stated as T1, NOS; Stated as T1a, NOS Use only when there is no information available to assign more specific code Discrepancies between clinician statement and documentation Documentation takes precedence Discuss case with clinician There will be many situations where the medical record includes a statement of T, N, and/or M without further details. For example, if a patient comes from another facility for more treatment, the admit note may only provide the T, N, and M and no specifics from the diagnostic procedures. In such cases, the “stated as” codes should be used. However, if copies of the diagnostic procedures are available to the abstractor, the details from the reports take priority. There will also be situations where there are discrepancies between the clinician’s staging and the documentation. In those cases, the documentation takes priority and the case should be discussed with the clinician. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS General Comments Obsolete codes
Necessary as a result of TNM 6 to 7 changes Splitting of previous codes Moving a structure from Extension to Mets at Dx Correcting mapping errors in CS version 1 Labeled in CSv2 Obsolete codes may be hidden in software Do not use obsolete codes for 2010 diagnoses and forward Retained as a reference for researchers Because the 7th edition changes in some sites were extensive, it was necessary to make some codes obsolete in CSv2. Most of these changes occurred because the existing extension codes contained information that fit into two subcategories in 7th edition and the existing code had to be split into two or more codes. In other sites, an involved structure was moved from Extension to Mets at Dx or vice versa. Consequently, the original code for the structure was made obsolete and a new code was created in the other field. In a few instances, codes were made obsolete in order to correct mapping errors in CS version 1. After the data validation review, more codes were made obsolete and new codes were created. Obsolete codes are plainly marked in CSv2 and should not be used for 2010 cases and forward. Registry software vendors have the option to hide the obsolete codes during the abstracting process, but in most cases the data collected in that code is still stored and available to researchers. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Part I Discussion of OBSOLETE
There is an expanded discussion of how obsolete data is handled in Part I of CS version This example shows some of the various definitions of obsolete, along with the actions that must be taken between versions 0202 and For example, some cases must be reviewed, some reviewed and manually recoded, and others can be converted by the computer during the installation and implementation of version 0203.

CS General Comments Inaccessible lymph nodes Accessible lymph nodes
Nodes within body cavities that cannot be palpated or easily examined Examples (not all-inclusive): regional nodes for bladder, kidney, colon, prostate, esophagus, stomach, lung, liver, corpus, ovary Accessible lymph nodes Breast, oral cavity, salivary gland, skin, thyroid, etc. Code regional nodes as negative if general statement in chart ‘remainder of exam negative’ The “inaccessible sites rule” existed in CS versions 1 and 0202, but it still needs some explanation. In CSv2, the rule remains but has been renamed and clarified as the “inaccessible nodes rule.” Inaccessible nodes are those in body cavities where they cannot be palpated for clinical examination, such as the regional nodes of the lungs, colon, bladder and prostate. Accessible lymph nodes are near the surface of the body, such as the regional nodes of the breast, oral cavity sites, skin and thyroid gland. For these sites, a physical examination is more likely, and there should be a statement in the medical record that the nodes were palpated or the exam was negative. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS General Comments Inaccessible lymph nodes rule
Record regional lymph nodes as NEGATIVE (rather than unknown) when no mention of LN involvement in PE, Dx testing or surgical exploration AND clinically early stage (T1, T2, localized) tumors patient receives ‘usual’ treatment to primary All three conditions have to be met Code unknown if reasonable doubt that tumor is not localized The inaccessible nodes rule itself has not changed in CSv Basically, it allows regional nodes to be coded as negative (000) when three conditions are met: 1. There is no mention of lymph node involvement in the diagnostic workup or surgical exploration prior to resection. 2. The patient has a clinically early stage tumor (confined to organ, T1 or perhaps T2). 3. The patient receives “usual” or “standard treatment” to the primary site appropriate to the stage at diagnosis. If there is any indication that the tumor is not localized, for example, if there is extracapsular extension of the primary, the registrar can code CS Lymph Nodes as 999 unknown. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS General Comments Schema Discriminator
Some primary sites have multiple schemas Example: Colon (carcinoma), GIST Colon, NET Colon, Lymphoma  determined by histology Some ICD-O-3 codes have multiple schemas Example: C24.0 Extrahepatic bile ducts (distal bile duct; cystic duct; right, left, and common hepatic ducts)  determined by schema discriminator Example: Nasopharynx includes pharyngeal tonsils. Nasopharynx has its own schema; pharyngeal tonsils are coded with oropharynx. Example: Peritoneum (usually soft tissue sarcomas, but sometimes primary peritoneal carcinoma in women) Schema discriminator brings appropriate schema to computer screen The schema discriminator field is required by all standards setters. Some organs have multiple schemas, such as colon. There are schemas for carcinomas of the colon, GIST of the colon, and neuroendocrine tumor of the colon as well as lymphoma. For colon cases, the histology determines which schema to use for coding the case. For other organs, additional information is necessary. This extra information is stored in site-specific factor 25 for sites where the ICD-O primary site code does not provide enough information for the computer algorithm to determine which schema to present to the abstractor. For example, the gender of the patient is necessary to “discriminate” between the schemas for peritoneum (primarily soft tissue sarcomas for males and females) and female genital peritoneum, which also includes carcinomas like primary peritoneal carcinoma (similar to ovarian carcinoma and staged similarly). For nasopharynx, code C11.1 includes both the posterior wall of the nasopharynx and the pharyngeal tonsils or adenoids. The posterior wall is included with other surfaces in the nasopharynx schema, but the adenoids are coded with the oropharynx. The CS version 1 schema for extrahepatic bile ducts was split into three schemas in CSv2: perihilar bile ducts, cystic duct, and distal bile duct. More on this in a few minutes. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS General Comments Unknown status of distant metastasis
No MX category in TNM 7th edition CS Mets at Dx code 99 (unknown) maps to M0 Registrar can assume no distant mets unless there is Evidence of mets clinically (physical exam, imaging, etc.) Microscopically proven distant mets Use code 00 instead It has been well publicized that in the TNM system MX, meaning that distant metastasis cannot be assessed, no longer exists. This has required some revision to CS version 2 mapping to TNM 7th edition. In CS version 1, CS Mets at Dx code 99 (Unknown) mapped to MX; in CS version 2, it maps to M0. A registrar can still use code 99, but it will map to the same TNM value as coding that the patient has no distant metastases. TNM 7th edition and CSv2 allow the registrar to assume that there are no distant metastases – and code as 00 in CS Mets at Dx – when there has been a minimal physical examination and there is no clinical or radiographic evidence of tumor at a distant site. In other words, the registrar should code CS Mets at Dx as 00 (none) rather than unknown unless there is definite proof that metastasis in a distant site is present at the time of diagnosis. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Eval Fields – General Guidelines
Assign Eval code that describes diagnostic procedure associated with corresponding data field May not be numerically highest Eval code Eval code relates to highest T, N, or M category, not necessarily to highest code in CS field Use a pathologic Eval code if a biopsy documents highest T, N, or M without resection One of the big changes in CSv2 is the result of a substantial shift in seventh edition staging rules. The shift affects how the method of evaluation or Eval fields are coded. TNM 7th edition allows some information from surgical procedures to be used for clinical staging. For example, when a tissue biopsy of a lymph node is performed to determine the extent of lymph node involvement (in other words, a diagnostic procedure as a means of deciding whether the patient should have neoadjuvant treatment), the information obtained from the biopsy is considered clinical information. When the information is obtained from a therapeutic procedure (such as an axillary dissection), the information obtained is considered pathologic. A lymph node procedure is considered pathologic when treatment of the primary site meets the criteria for a pathologic T or when the lymph node procedure documents the highest N category. In addition, the coding instructions have clarified that the Eval code is intended to correspond to the highest derived T, N, or M category, which may not be the highest code in the CS field. For example, the patient has a cervical carcinoma with bullous edema of bladder (CS Extension code 600, maps to T3a) diagnosed by tissue biopsy during cystoscopy. KUB radiography (CS Tumor Size/Eval code 0) shows non-functioning kidney (CS Extension code 630, maps to T3b). Code CS Tumor Size/Ext Eval as 0 because the imaging documented a higher subcategory of T3 than the cystoscopy. If a biopsy documents the highest T, N, or M category, the Eval code should be one that maps to the pathologic staging basis. In a similar example, the cervical cancer patient has a biopsy proven diagnosis of tumor extension to the inside of the bladder (code 700, maps to T4). Because the highest T category has been pathologically proven, the Eval code should be coded to 3. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS Nodes Eval – Rules Linked to CS Lymph Nodes
Code as clinical or pathologic based on intent of procedure and assessment of T If LN procedure part of workup, staging basis is clinical (codes 0, 1, 5, 9) If LN procedure part of treatment, code as pathologic (codes 2, 3, 6) Must have resection of primary site meeting pT criteria To illustrate this change in the TNM seventh edition rule that affects CSv2, take the example of CS Nodes Eval. This field describes how the CS Lymph Nodes code was determined. The new guidelines for coding Nodes Eval as clinical or pathologic are based on the intent of the lymph node procedure—whether it was diagnostic or therapeutic—and whether the primary site procedure meets the criteria for pathologic staging. Both the primary site and the lymph nodes must be considered when the Nodes Eval field is coded. In other words, when the intent of the lymph node procedure is workup, the staging basis is clinical, and when the intent is treatment, the staging basis is pathologic If the lymph nodes procedure is part of the work up, Nodes Eval should be coded with a value that maps to clinical staging basis. For example, if a sentinel node biopsy is done to determine whether the patient should have pre-operative radiation or chemotherapy, the Nodes Eval code would be 1, defined as fine needle aspiration, incisional core needle biopsy, or excisional biopsy of regional lymph nodes or sentinel nodes as part of the diagnostic workup, WITHOUT removal of the primary site adequate for pathologic T classification (treatment). On the other hand, if the lymph node procedure is part of the patient’s treatment, Nodes Eval should have a code that maps to pathologic staging basis. For example, if the patient has a lumpectomy and a sentinel node biopsy either at the same time or as a separate procedure afterward, the sentinel node biopsy is pathologic, because the lumpectomy meets the criteria for pathologic staging of the primary site. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS Nodes Eval – Rules, cont’d
Most sites use standard table General structure 0 Clinical only; no nodes removed 1 No nodes removed; endoscopy or invasive techniques; surgical observation OR FNA, needle bx; or excisional bx as part of diagnostic workup without removal of primary site sufficient for pT Bx does not meet criteria for pathologic N 2 Autopsy (known or suspected dx) In CSv2, additional wording has been added to codes 1 and 3 of the Nodes Eval field to clarify that treatment of the primary site must be taken into consideration when selecting the Nodes Eval code. The additional wording also makes it clear that code 1 does not meet the criteria for a pathologic N… CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

General structure, cont’d 3 Any microscopic assessment of regional nodes WITH removal of primary site sufficient for pT OR Positive biopsy of highest N category regardless of T Meets criteria for pathologic N 5 Pre-op tx and resection; clinical evidence 6 Pre-op tx and resection; path evidence more extensive 8 Autopsy (dx not suspected) 9 Unknown, not assessed; no TNM schema …and code 3 does meet the criteria for pathologic N. Thus code 3 also includes wording that states that any biopsy that documents the highest N category meets the criteria for pathologic staging of lymph nodes. An example would be a lung cancer case where the patient has a positive biopsy of a supraclavicular lymph node (CS Lymph Nodes code 600). Supraclavicular nodes are N3, the highest category of N for lung, so the biopsy should be coded 3 in Nodes Eval. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Code 9 Always 9 for sites without TNM mapping Avoid 9 if possible when CS Lymph Nodes is 999 Sentinel nodes Code as pathologic when tumor size/extension meets criteria for pT When no pT, exam of single LN or sentinel nodes is clinical Code as pathologic when there is a positive biopsy of node in highest N category This slide is a reminder that some sites are always coded 9 in Nodes Eval. These include sites where there is no TNM mapping and a few sites where the CS Lymph Nodes field is not used, such as brain and lymphoma. In the situations where it is not possible to assess the status of lymph nodes (CS Lymph Nodes is coded 999), the method(s) used are usually known. So even though CS Lymph Nodes is coded as 999, code 9 in Nodes Eval should be avoided because that means that the diagnostic methods are not known either. Sentinel node procedures performed in conjunction with resection of the primary site are coded as pathologic. Sentinel node procedures performed without resection of the primary site are coded as clinical. ANY lymph node procedure that confirms that lymph nodes in the highest N category are involved is coded as pathologic. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Regional Nodes Positive/Examined General Rules
Counting nodes (positive or examined) Do not count positive aspiration or core biopsy of node in same chain removed at surgery Do count positive aspiration or core biopsy of node in different region If location of biopsied/aspirated node unknown, do not count Priority of node counts Final dx, synoptic report, microscopic, gross Several issues regarding the counting of lymph nodes positive and lymph nodes examined have been clarified in CSv2. The first pertains to whether aspirated lymph nodes are counted when more lymph nodes are resected. When an aspirated or biopsied lymph node is in the same chain as lymph nodes that are surgically removed, it is NOT added to the counts of lymph nodes positive and examined. The same applies if it is unknown whether the aspirated/biopsied node is in the same chain as the resected nodes. When an aspirated or biopsied lymph node is in a different chain from nodes that are surgically removed, it IS added to the counts of lymph nodes positive (if appropriate) and examined. For example, an axillary lymph node is aspirated and found to be positive. The patient undergoes an axillary dissection showing 3 of 12 nodes involved. The final count of nodes positive and nodes examined is 03 and 12. In another example, the patient has a core biopsy of a supraclavicular lymph node which is negative and a Level I and II axillary dissection showing 4 of 10 nodes positive. The final count for this case would be 04 positive and 11 nodes examined, adding the negative biopsied node to the total of nodes examined. Finally, we all know that counts of nodes positive and examined vary through different parts of the pathology report. CSv2 coding guidelines now provide a priority for lymph node counts: information from the final diagnosis comes first, followed by the synoptic report or CAP protocol, then the microscopic examination and the gross examination as lowest priority. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS Mets at Dx Rules Generally used for discontinuous, blood-borne, or fluid-borne mets and involved distant lymph nodes Code the farthest documented metastasis Usually clinical or inferred If no pre-op tx: path when available; if pre-op tx: clinical Mets at Dx codes (general structure) 10 Distant lymph nodes 40 Specific named structures or carcinomatosis 50 Distant nodes plus distant mets 60 Nonspecific distant metastases There have been some changes in the Mets at Dx field as well, although not as significant as for the Eval fields. As in CS version 1, the farthest documented metastasis is coded, but now there are “stated as” codes—especially when M1 has been split into subcategories—and a new code 60 has been added to most schemas to cover non-specific distant metastases. This reserves code 40 for specific named distant structures or carcinomatosis and code 60 is used for “distant metastasis, NOS.” CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CS Mets at DX When to code 00 vs. 99 No MX in TNM 7th edition
Code 00 when No clinical or pathologic evidence of distant mets and patient is not treated as if mets are present or suspected Only history and physical exam needed Code 99 when Reasonable doubt that tumor no longer localized Maps to MX in TNM 6th edition and M0 in 7th edition No MX in TNM 7th edition Registrar can code Mets at Dx 00 unless distant mets are identified and classified as cM1 or pM1 CTCs and DTCs Breast only: code as 05 Code 98 Lymphoma, heme-retic, and some other sites As mentioned previously, there is no MX in the seventh edition of TNM. Therefore, in CSv2, code 99 (unknown or not assessed) maps to M0. Only a history and physical examination are needed to assign a clinical M0 to a case. Code 99 can be used when there is reasonable doubt that the primary tumor is no longer localized, but it would make more sense to code 00 unless distant metastases are identified clinically or pathologically. Breast has an additional new code 05, which can be used for circulating tumor cells (CTCs in the blood) or disseminated tumor cells (DTCs in the bone marrow or other distant sites). CTCs and DTCs are the metastatic equivalent of isolated tumor cells in lymph nodes. Researchers and clinicians are not sure whether they have true malignant metastatic potential, so for breast, code 05 maps to M0. For lymphoma, the hematopoietic and reticuloendothelial diseases, and a few other sites, CS Mets at Dx is coded as 98 for not applicable. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Site-Specific Factors
25 SSFs available Needed for TNM mapping Tumor markers and lab values Prognostic/predictive Future research/special interest Associated diseases and conditions One of the big changes in CSv2 is the expansion of the site-specific factors from 6 to 25. Most of the new site-specific factors were suggested by the authors and editors of the AJCC Cancer Staging Manual seventh edition to make TNM more clinically relevant. A few are necessary for complete capture of information needed for registry purposes. There are many different types of information captured in the site-specific factors. Items are needed for TNM mapping, such as the number of positive level I and II axillary lymph nodes for breast. Tumor markers and lab values, such as CA19-9 for stomach, pancreas, and bile ducts and Ki-67 for central nervous system and ophthalmic sites. Prognostic and predictive items such as HER2 for breast. Research and special interest items such as microsatellite instability for GI cancers. Associated diseases and conditions related to the primary cancer, such as a history of asbestos exposure for pleural mesothelioma. Many of these items will be discussed in more detail in a separate training module on site-specific factors. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Coding of Lab Test Interpretation
Priority of information Code clinician’s interpretation If no MD interpretation, registrar may interpret from reference range listed on lab report If no MD interpretation and no reference range listed, code as 999 Use common sense and code 010 rather than 999 if lab result is extremely abnormal A new guideline was added to the discussion of site-specific factors in Part I Section 1 documentation of CSv It pertains to how the registrar can use information in the medical record when the clinician does not provide an interpretation of lab test results. As a first priority, code the clinician’s interpretation of the lab result, such as a statement of abnormal, elevated, normal, present, absent, and so forth. In addition, the registrar can infer from a physician’s statement of a T, N, or M value whether a lab value used to determine the TNM classification was abnormal or normal. If the clinician makes no statement and the lab report itself is available in the medical record, the registrar can compare the lab result and the reference range information on the lab report and code that information. In the absence of a clinician statement and the lab report itself, code 999 for unknown should be used. Note that there will be some circumstances where the lab result is extremely abnormal and common sense will dictate that the case should be coded as 010 Abnormal rather than 999.

Use of SSF 900 Series Codes 987 Not applicable (case does not meet
criteria for SSF) 988 Not applicable: information not collected for this case 997 Test ordered, results not in chart 998 Test not ordered OR No histologic examination of primary site 999 Unknown; not documented Site-specific factor codes in the range 980 to 999 have special meanings, and individual codes other than 999 are not used in every schema. These are the general uses for some of these codes: Code 987 usually means “not applicable” because the case does not meet the criteria for the site-specific factor. For example, breast SSF4 Immunohistochemistry of regional nodes includes 987 as a code to use when the case has positive lymph nodes and IHC of negative nodes is not applicable. Code 988 means “Not applicable: information not collected for this case.” This code should not be used when the individual site-specific factor is required by one of the standards setters that the registry reports to. The code can be used if the site-specific factor is not required by the standards setter. For example, HER2 fields are required by all US standards setters, so code 988 cannot be used for a case without generating an error message. In contrast, the site-specific factor for CA 19-9 for stomach is not required by any standards setter. If a registry chooses not to collect this information, code 988 is appropriate. Code 997 means “Test ordered, results not in chart” for most schemas where the code appears. This code can be used when the lab results are not in the medical record. For example, if a tumor marker is mentioned in the medical record but the SSF requires a coded value, use code 997 to indicate that the test was performed but an actual value could not be coded. Code 998 in many schemas means “no histologic examination of primary site” and should be used when the site-specific factor captures pathologic information and there was none for the case. It can also mean “test not done; test not ordered and not performed.” This code can be used when there is a statement in the medical record that the test was not done. For example, if there is not enough tissue from breast tumor to send for ER, PR, and HER2 evaluation, code 998 is appropriate. In either case, code 998 indicates why there is no test result for the site-specific factor. Code 999 means “not documented,” “no information available in medical record,” or “unknown.” This is the default code when the site-specific factor cannot be coded because the information simply is not available. Use these codes sparingly. If better information is available, use that as a priority.

Sites with Major Changes

CSv2 Schema Changes Organ schemas split by morphology Head and neck
Mucosal melanoma vs. carcinoma Liver and intrahepatic bile ducts separate Liver (Hepatocellular carcinoma) Intrahepatic bile ducts (Cholangiocarcinoma) GI tract GIST vs. NET vs. carcinoma One of the reasons for the nearly two-thirds increase in the number of CSv2 schemas is the separation of a large number of primary sites by histology. Many head and neck sites now have a schema for carcinoma and a separate schema for mucosal melanoma. Where liver and intrahepatic bile ducts have separate primary site codes and separate schemas in CSv2, hepatocellular carcinomas—even if stated as arising in an intrahepatic bile duct—are coded with the liver schema, and cholangiocarcinomas—even if stated as arising in the liver—are coded with intrahepatic bile ducts. In various organs of the gastrointestinal tract, there are separate schemas for carcinoma versus gastrointestinal stromal tumor versus neuroendocrine tumor. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

GI Tract Schemas Carcinoma GIST NET Esophagus  Esophagus-GEJunction
Stomach Small Intestine Appendix Colon Rectum Anus Here you can see that the number of histology specific schemas varies by the location of the tumor within the gastrointestinal tract. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

CSv2 Schema Changes Organ schemas split by morphology Corpus uteri
Carcinoma vs. adenosarcoma vs. sarcoma Skin Cutaneous SCC and Other Cutaneous Carcinoma Merkel cell Malignant melanoma Esophagus Separate TNM stage mapping for squamous vs. adenocarcinoma Based on 2009 revisions to the International Federation of Gynecology and Obstetrics staging of corpus uteri cancers that were adopted by the AJCC, corpus cancers are now coded according to separate schemas for carcinomas, adenosarcoma, and sarcoma. Skin cancers now have three schemas: Merkel cell, which is new; malignant melanoma; and all of the remaining skin cancers in a schema called “Cutaneous squamous cell carcinoma and other cutaneous carcinoma.” And although it does not affect coding in the esophagus schema, there are separate stage groupings for squamous and adenocarcinomas of the esophagus in the 7th edition. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Schemas Split/Revised
Extrahepatic bile ducts (C24.0) split into Perihilar (proximal) bile ducts Cystic duct Distal bile duct Esophagus (GE Junction) now includes Gastroesophageal junction (C16.0) Stomach fundus (C16.1) Part of stomach body (C16.2) Peritoneum Retroperitoneum GIST peritoneum Peritoneum Female Genital Three other organs have been split into separate schemas requiring further definition of the primary site. The first is the extrahepatic bile ducts, all of which are coded to C The 7th edition has separate staging systems for the perihilar bile ducts (right, left and common hepatic ducts), the cystic duct connecting the gallbladder to the common bile duct (staged with gallbladder), and the common bile duct, now referred to as the distal bile duct. Because all of these structures are coded to the same primary site code, it was necessary to add a data field to differentiate the names of the structures. More on this in a moment. The authors of the esophagus chapter in the seventh edition of the AJCC Cancer Staging Manual included the gastroesophageal junction and part of the stomach itself in the esophagus staging. Because some parts of the stomach are now coded with the esophagus schema and other parts are coded with the stomach schema, it has been necessary to add a data field that names the exact location of the stomach lesion so that the registry software knows which schema to bring to the screen. And because the peritoneum has the potential to develop not only soft tissue sarcomas and gastrointestinal stromal tumors but also primary peritoneal carcinomas similar to those that develop in the ovaries, it has been necessary to add a data field that asks the gender of the patient in order to bring the correct schema to the screen. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

C24.0 Extrahepatic Bile Ducts
In ICD-O-3, all of the hepatic ducts, the cystic duct, and the common bile duct are coded to C Therefore a “schema discriminator” field is necessary to code the verbal description of the tumor location. Illustrations such as this one from the AJCC Cancer Staging Atlas are included in CSv2 to assist the registrar in determining the precise location of the primary tumor. Extrahepatic Bile Ducts. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: ©American Joint Committee on Cancer. Used with permission of the (AJCC®, Chicago, Illinois. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

SSF 25 Subsite of Extrahepatic Bile Ducts
010 Perihilar bile duct(s); Proximal extrahepatic bile duct(s); Hepatic duct(s) BDPerihilar 020 Stated as Klatskin tumor BDPerihilar 030 Cystic bile duct; cystic duct CysticDuct 040 Common bile duct; Common duct, NOS BDDistal 050 Diffuse involvement; > 1 subsite involved, subsite of origin not stated BDPerihilar 060 Subsite of extrahepatic bile ducts not stated, but treated with combined hepatic and hilar resection BDPerihilar 070 Subsite of extrahepatic bile ducts not stated, but treated with pancreatico- duodenectomy BDDistal 999 Subsite not stated and not classifiable in codes BDPerihilar This is site-specific factor 25, the schema discriminator for the extrahepatic bile ducts. If the specific location of the tumor is named, it can be coded in 010 to A Klatskin tumor (code 020) is an adenocarcinoma that develops at the junction of the right and left hepatic ducts. Only the duct between the gallbladder and the common bile duct uses the Cystic Duct schema. There will be a few situations where the specific location is not mentioned or cannot be determined. In such cases, look at how the tumor is treated—code the schema discriminator as 060 (use the perihilar bile ducts schema) if the patient has a liver procedure, and code 070 (use the distal bile ducts schema) if the patient has a pancreas procedure. The default when the subsite is not stated is to use the perihilar bile ducts schema. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

C24.0 Extrahepatic Bile Ducts
Perihilar BD schema Distal BD schema Cystic Duct schema Common bile (choledochal) duct  Cystic bile duct Hepatic bile duct – right, left, common Klatskin tumor Sphincter of Oddi Extrahepatic bile duct [NOS] This is a less wordy display of how the extrahepatic bile duct sites sort out in the three new schemas. If the specific duct is unknown, the case will end up being coded with the perihilar bile duct schema. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Esophagus-Stomach Changes
Shift of C16.0, parts of C16.1 and C16.2 to esophagus schema Esophagogastric junction (EGJ) tumors: If midpoint (epicenter) within 5 cm of EGJ and also extends into esophagus, classify and stage as esophagus Stage all others with midpoint in stomach > 5 cm from EGJ or those within 5 cm of the EGJ with no extension into esophagus as gastric carcinoma Adenocarcinomas of the stomach that involve or extend past the esophago-gastric or gastroesophageal junction are handled as esophageal cancers, even though the EG junction and proximal stomach are included with the stomach codes. The authors of the 7th edition esophagus and stomach chapters came to agreement that any tumor of the upper stomach that extends into the lower esophagus should be classified and staged as an esophageal tumor. This includes the cardia or GE/EG junction (C16.0) and the proximal 5 centimeters of the fundus (C16.1) and body (C16.2) of the stomach. Tumors in the fundus and body that do not extend beyond the GE junction are classified and staged as stomach tumors. Sorting this out requires some extra programming that is transparent to the abstractor, who simply codes the verbal description of the primary site location in the “schema discriminator” field, which is stored in site-specific factor 25. The computer algorithm determines from that information which schema to bring to the screen. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

New Schema: Esophagus GE Junction
Esophagogastric Junction Gastroesophageal Junction The area in the red box is coded using the new Esophagus GE Junction schema. As you can see, the area includes part of the fundus of the stomach C16.1 and part of the body of the stomach C16.2 within 5 centimeters of the cardia or GE Junction. As noted, any tumor in this 5 cm area of the upper stomach that involves the GE junction or extends into the lower esophagus is now coded with the esophagus-GE Junction schema in CSv2. A tumor in this area that does not involve the lower esophagus or GE junction is coded with the stomach schema. From Edge et al. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, seventh edition (2009) published by Springer Science and Business Media LLC, CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

SSF 25: Involvement of Cardia and Distance from GE Junction
000 No involvement of esophagus or EGJ Stomach 010 Tumor located in Cardia or EGJ EsophGEJ 020 Esoph or EGJ involved AND tumor midpoint from EGJ ≤ 5 cm EsophGEJ 030 Esoph or EGJ involved AND tumor midpoint from EGJ > 5 cm Stomach 040 Esoph or EGJ involved AND tumor midpoint from EGJ unknown EsophGEJ 050 Esoph and EGJ not involved but tumor midpoint from EGJ is ≤ 5 cm Stomach 060 Esoph involved or esoph involvement unknown AND tumor midpoint from EGJ > 5 cm or unknown AND MD stages case using esoph definitions EsophGEJ 999 Involvement of esoph not stated, unk or no info, not documented Stomach Blank for Stomach cases C16.3-C16.9 Stomach Blank for Cardia/EGJ cases C16.0 EsophGEJ This is the “schema discriminator” field that tells the registry software program which schema to present to the coder. You can see that it is important to know how far from the esophagogastric junction is the center or midpoint of the adenocarcinoma. This field is left blank if the primary site code is something other than C16.1 or C It defaults to the Esophagus GEJunction schema if the esophagus or GE junction is involved and the distance to the junction is unknown, and defaults to stomach if involvement of the esophagus is not stated. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Peritoneum Retroperitoneum C48.0 only Peritoneum C48.1-C48.2, C48.8
All sarcoma histologies except Peritoneum C48.1-C48.2, C48.8 Males: , , , Females: , , , 9141- 9582, Peritoneum Female Genital , , , GIST Peritoneum only The retroperitoneum and peritoneum schemas appear somewhat bewildering at first glance, but if you think in terms of histology groups and gender, they are easier to understand. Retroperitoneum is a single primary site code and includes both males and females and all sarcomas except gastrointestinal stromal tumors. No adenocarcinomas are coded to retroperitoneum as a primary site. The peritoneum schema is used for three primary site codes, specified parts of peritoneum including omentum and mesentery; peritoneum, NOS; and overlapping lesion of retroperitoneum and peritoneum. For males, the peritoneum schema includes all carcinomas and sarcomas with the exception of gastrointestinal stromal tumors and Kaposi sarcoma, as well as mycosis fungoides and Sezary syndrome. For females, the peritoneum schema includes thymomas, paragangliomas and melanomas (all extremely rare), blood vessel, lymphatic vessel, bone, and miscellaneous sarcomas (also rare) except Kaposi sarcoma. All other carcinomas and sarcomas except gastrointestinal stromal tumors in females are coded using the Peritoneum Female Genital schema. This histology code range includes the primary peritoneal carcinomas that are similar to histologies that arise in the ovaries. A separate GIST of peritoneum is similar to the GIST schemas for gastrointestinal sites. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

SSF 25 Peritoneum Schema Discriminator
001 Male Peritoneum 002 Female PeritoneumFemaleGen 003 Other (hermaphrodite) Peritoneum 004 Transsexual Peritoneum 009 Unknown sex Peritoneum A schema discriminator used in the Peritoneum and PeritoneumFemaleGen schemas is necessary to differentiate these two schemas by gender. All of the choices in the Sex data field use the peritoneum schema except code 002 Female. The separate PeritoneumFemaleGen schema permits the mapping of primary peritoneal carcinomas to TNM using the same staging criteria as ovarian cancers of these histologies. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Lymph-Vascular Invasion (1)
Coding instructions Based on all pathology reports or information available Priority given to positive results Includes lymphatic invasion, vascular invasion, or lymph-vascular invasion Do not use for perineural invasion Use CAP checklist as primary source Other sources may be used in the absence of a checklist Lymph-vascular invasion is an item mentioned in many 7th edition chapters. This is a data field separate from CSv2 items but defined in the CS Manual. For a few sites including testis, this field must be completed in order for the computer algorithm to correctly map to T in TNM. Lymph-vascular invasion is defined as the presence of tumor cells found inside small blood vessels or lymphatic channels WITHIN THE TUMOR and surrounding tissues IN THE PRIMARY SITE. The tumor cells have broken free of the primary tumor and now have the capability to float throughout the body. This is sometimes called lymphovascular invasion or LVI, lymphatic invasion, vascular invasion or blood vessel invasion, and the presence of lymphatic or vascular invasion may affect the patient’s prognosis. This field records any tumor cell invasion in lymphatic channels (not lymph nodes) or blood vessels as noted microscopically within the primary tumor by the pathologist. Perineural invasion is not coded in this field. The synoptic reports or pathology checklists developed by the College of American Pathologists are the primary source, but this information may be noted anywhere in a pathology report. If lymph-vascular invasion is seen anywhere in the specimen, it should be coded as positive. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Lymph-Vascular Invasion (2)
Code structure 0 – Lymph-vascular invasion not present (absent)/Not identified 1 – Lymph-vascular invasion present/identified 8 – Not applicable 9 – Unknown/Indeterminate The code structure is straightforward: use code 0 when lymphatic or vascular invasion is absent (not identified by the pathologist) and code 1 when lymphatic or vascular invasion is present. If the pathologist cannot determine whether lymph-vascular invasion is present, or if LVI is not mentioned, use code 9. Code 8 is used for the lymphomas and hematopoietic and reticuloendothelial diseases. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

Summary Read and understand the CS general rules
Do not rely on memory when coding Refer to the site-specific schema every time Read the notes for each data field Understand the anatomy Primary site, adjacent structures and regional nodes Record the most extensive code Greatest size/extension or farthest documented mets Use NOS and “Stated as” codes as last resort Understand the new definitions of the Eval fields Code SSFs as required In summary, it is important that the registrar read and understand the CS general rules that apply to all types of cancers. Part I of the Collaborative Staging Manual has been updated with additional clarifications based on user comments and questions. As you code 2011 cases, do not rely on your memory. Refer to the site-specific schema every time a case is abstracted. A number of codes were made obsolete between versions 0202 and 0203 and replaced by new codes and modified definitions. It is also important to read the notes for each data field as the notes may affect the choice of code. Know what structures are included with, and adjacent to, the organ and which nodes are regional for the organ. Record the most extensive specific code that can be supported by the medical record. Sometimes a more specific code will be numerically lower than a general or non-specific code or a “stated as” code. Avoid the NOS and “Stated as” codes unless there is no more specific information available. Understand the revised definitions of the Eval fields, particularly for CS Lymph Nodes Eval and when lymph node procedures meet the criteria for clinical or pathologic staging. Know which site-specific factors are required by your standards setters, and understand when various codes can be used within the SSFs. CSv2 Overview – CSv2 What’s New Presentation Sept 15, 2009 Version: 2.0

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: CS Web Site: CSv2 Bladder, Kidney & Testis June Lecture Version: 1.0

Part 1 Section 1 Coding Instructions Education and Training Team

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Part 1 Section 1 Coding Instructions Education and Training Team

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