1. TRAM Educational Conference March 15, 2013 Anne Arundel Medical Center

2. Objectives: Discuss various data items and increase awareness of accurate coding practices by Maryland Registrars. Discuss the importance of accurate coding and understanding of data items presented. Tips on working smarter not harder. Update from the MCR

3. Codes 1 Hospital inpatient 2 Radiation Treatment Centers or Medical Oncology Centers 3 Laboratory only 4 Physician’s office/private medical practitioner 5 Nursing/convalescent home/hospice 6 Autopsy only 7 Death certificate only 8 Other hospital outpatient units/surgery centers

4. This data item is intended to indicate the completeness of information available to the abstractor. Code in the following priority order: 1, 2, 8, 4, 3, 5, 6, 7 Sources with ‘2’ usually have complete information on the cancer diagnosis, staging, and treatment.

5. Codes 1 Hospital inpatient 2 Radiation Treatment Centers or Medical Oncology Centers 3 Laboratory only – use only if the cases are considered lab only. 4 Physician’s office/private medical practitioner – do not use unless you have an agreement w/ physicians’ office to report for them. 5 Nursing/convalescent home/hospice 6 Autopsy only 7 Death certificate only 8 Other hospital outpatient units/surgery centers

6. Sources coded with ‘8’ would include, but not limited to, outpatient surgery and nuclear medicine services. A physician’s office that calls itself a surgery center should be coded as a physician’s office. Surgery centers are equipped to perform surgical procedures under general anesthesia.

7. If you are entering multiple race codes and one includes ’01’ for white, placement of ’01’ should be last in the sequence Reminder that Hawaiian trumps all other races.

8. NO CS Data Fields Required Leave all CS data fields blank From CS tumor size to SSF25

9. Use code 8 for cases that have no microscopic examination of a primary specimen and for the following primary sites:  Hodgkin and Non-Hodgkin Lymphoma  Leukemia  Hematopoietic and reticuloendothelial disorders  MDS including refractory anemia and refractory cytopenia  Myeloproliferative disorders

10. Heme/Lymphoid neoplasms should be coded to 7 to reflect systemic disease.

11.  CS Mets Brain = 0  CS Mets Bone = 0  CS Mets Liver = 0  CS Mets Lung = 0 If Date of Diagnosis is > 2004/1/1 otherwise leave blank

12. You MUST have histologic examination of the pleura to code this field. This can only be accomplished with a resection. A biopsy doesn’t provide enough tissue to establish pleural involvement. Imaging doesn’t provide the histologic confirmation. Use code 998 when there is no histologic examination of the pleura.

13. Note 2: Code results as stated on the pathology report. Code 998 if no histologic examination of pleura to assess pleural layer invasion. Note 3: If pleural/elastic layer invasion (PL) is not mentioned on the pathology report from a resection, code 999.

14. Note 4: An FNA is not a histologic specimen and is not adequate to assess pleural layer invasion. If only an FNA is available, use code 998. Note 5: Metastasis to the pleura, that is pleural tumor foci or nodules separate from direct invasion, are coded in CS Mets at Dx (code 24).

15. CS Site-Specific Factor 15 - HER2: Summary Result of Testing This variable is based on CS Site-Specific Factors 9, 11, 13, and 14. SSF 15 should reflect the test interpretation of either IHC, FISH, CISH or other/unknown test. If SSF9 = 020 then SSF15 should also = 020

16. CS Site-Specific Factor 15 - HER2: Summary Result of Testing If both an IHC and a gene-amplification test (FISH or CISH) are performed, record the result of the gene-amplification test in this field. However, if the gene-amplification test is given first and the result is borderline or equivocal and an IHC test is done to clarify these equivocal results, code the result of the IHC test.

17. CS Site-Specific Factor 15 - HER2: Summary Result of Testing If the results of one test are available, and it is known that a second test is performed but the results are not available, use code 997.

18. Note 7: For CS Extension - Clinical Extension codes 200 - 240 without prostatectomy assign CS Tumor Size/Ext Eval code 0 as these extension codes are based on physical examination and/or imaging only and NOT biopsy.

19. Code 0000 if the patient is alive Code 7777 if the patient is deceased and the death certificate is not available. You may use this field to reflect cause of death at your facility. We overwrite when we conduct death follow-back activities.

20. Be sure to use the correct ICD revision number for coding Cause of Death. Mortality codes from the death certificate are coded in ICD- 10, otherwise, this field should be coded to either: 0 – patient is alive 9 – ICD- 9 -CM

21. A skin biopsy of any technique (shave, punch, incisional) that shows GROSS residual disease is coded in Surgical Diagnostic and Staging Procedure as 02. A biopsy with positive margins invisible to the eye, but visible by microscope is coded as an excisional biopsy, Primary Surgery codes 20 – 27. Re-excisions are coded to 30 – 33.

22. Do not code excisional biopsies with clear or microscopic margins in the Surgical Diagnostic/Staging Procedures field. Code in Surgery Primary Site

23. In-situ Melanoma – SSF 3 should = 005 005 Clinically negative lymph node metastasis AND No pathologic examination performed Or unknown if pathologic examination performed Or nodes negative on pathologic examination

24. A diagnostic TURB is considered surgery and should not be coded in the Diagnostic/Staging Procedures. Use code 27 in the Surgery Primary Site to record TURB’s

25. BCG Therapy for Bladder cancer should be coded in both the Surgery Primary Site field and the BRM field. 10 Local tumor destruction, NOS 11 Photodynamic therapy (PDT) 12 Electrocautery; fulguration (includes use of hot forceps for tumor destruction) 13 Cryosurgery 14 Laser 15 Intravesical therapy 16 Bacillus Calmette-Guerin (BCG) or other immunotherapy

26. Typically, BCG is administered weekly for 6 weeks. Another 6-week course may be administered if a repeat cystoscopy reveals tumor persistence or recurrence. Recent evidence indicates that maintenance therapy with a weekly treatment for 3 weeks every 6 months for 1-3 years may provide more lasting results. Periodic bladder biopsies are usually necessary to assess response.

27. From the Canswer Forum: If a patient with a urothelial bladder primary has a TURB followed immediately by BCG how would we code treatment. Would we assign surgery as 27 and immnunotherapy as 01 or would we assign two surgical procedures and give one a code of 16 and the other a code of 27 and then also code immunotherapy as 01. Could you give some background as to why we code BCG and intravesicle chemo in the surgery codes?

28. This question was answered by Jerri Linn Phillips who is manager of NCDB and editor of FORDS. "As to the final question, years ago when I asked why the BCG instillation code was in surgery, I was told that the surgeons on the manual’s update team wanted it there.” The purpose of the primary site surgery codes is to describe what was removed from the patient. BCG instillation is grouped with the ‘10s’ numeric series (no pathology) because it does not itself involve tissue removal though a surgeon and surgical prep may be part of the procedure. The BCG itself should be coded in immunotherapy, so that information is retrievable under any circumstances. Only if no other surgery was performed should the BCG instillation code be used.

29. Therefore, if any surgery with a code 20 or above also applies, it should be coded for surgery and the applicable BRM code assigned. If a hospital performs multiple primary site surgeries, each successively is coded so that it includes all tissue previously surgically removed (BCG does not do its thing surgically). See the first full paragraph at the top of page 22 in FORDS: Revised for 2011. The code given when the last surgery was performed will include the earlier surgery, and therefore it will include the TURB even if it is followed by the BCG. That is why 16 is not coded when something 20 or higher has been coded. This is because we want to know what was removed from the patient; the codes were not designed to capture series of multiple intervening surgeries.

30. Adenocarcinoma, intestinal type (8144) is a form of stomach cancer. Do not use this code when the tumor arises in the colon.

32. Social Media – Facebook I am a manager of a medium to large sized registry (1400+ cases a year) in the process of training two non-CTRs (no other CTRs except myself). One is 6 months into the job the other is 1.5 yrs. They are fairly independent at this point and are producing abstracts that need to be QA'd for accuracy and completeness. I have been doing 100% QA but am finding it more difficult to keep up with the volume. Can anyone offer some ways to cut down the time it is taking to QA (we re-abstract for the most part) without jeopardizing the importance of receiving meaningful feedback that lends to effective learning. Any suggestions are welcome!

33. RUN REPORTS!!! Take a day and set up and save some QA reports that can be used to check the quality of individual abstractors data. For example: Query on one abstractors initials and see if they’re coding histology correctly for papillary carcinoma of the thyroid. 8050 vs. 8260 for C739

34. Benign Brain tumors Check meningiomas to confirm behavior code of ‘0’ and sequence number 60. Lung Cancer Check SSF 2 against the surgery codes. If surgery codes are less than a wedge resection, then SSF 2 should = 998

35. Use GenEdits Create a file with cases from each abstractor, individually. Run that file through GenEdits and see what the results are. Be sure to log or maintain some documentation of your QA activities!! You can manage 10% re-abstracting

36. You can manage 10% re-abstracting if you’re running some type of edits reports and documenting the findings. By having the abstractors correct their own work, it’s a great learning tool.

37. QUESTIONS??

38. Passwords Stronger passwords will be requested on and after April 1, 2013 8 – 20 characters Must contain at least one digit Must contain at least one upper and one lower case letter Must contain at least one special character (!@#$%)

39. Disease Indices Reinstatement of annual submission of disease indices WHY??? Completeness Death Follow-back

40. Disease Indices Submission by March 1st each year (since we’ve missed the deadline this year, please submit by May 1 st ) Reminders will be sent via email Call us if this will be delayed or if assistance is needed

41. Disease Indices Submission by May 1 each year Reminders will be sent via email Call us if this will be delayed or if assistance is needed

42. Disease Indices Format Excel -.xls or.xlsx CSV – comma separated value

43. Disease Indices MUST include all elements outlined in the instructions. MUST include Jan – Dec of the previous year.

44. QUESTIONS??