1. KCR 2014 Spring Training CHANGES IN CODING GRADE

2. Changes in coding grade Grade has long been a source of confusion…

3. Changes in coding grade Several issues complicate matters:  in situ vs invasive  terminology vs numbers  special rules for many sites  FORDS and SEER manual have different instructions

4. Changes in coding grade  SEER, CDC, and CoC formed a work group to address the problem  No new codes; only clarifications and changes to instructions  New rules apply to cases diagnosed January 1, 2014 forward

5. Changes in coding grade  Instructions for coding cell indicator in hematopoietic and lymphoid neoplasms (codes 5, 6, 7, 8, 9) have not changed  Determine cell indicator using the “Grade of Tumor Rules” in Hematopoietic and Lymphoid Neoplasm Manual

6. Changes in Coding Grade  For solid tumors, grade is a measurement of how closely the tumor cells resemble the tissue from the organ of origin  Similarities and differences may be based on pattern (architecture), cytology, nuclear features, or a combination of these  Depends upon which grading system is used

7. Changes in coding grade  Pathologists describe tumor grade using three systems:  Two levels of similarity (two-grade system)  Three levels of similarity (three-grade system)  Four levels of similarity (four-grade system)

8. Rules for coding solid tumors 1) Code grade based on information prior to neoadjuvant therapy, even if grade is unknown 2) Code grade from the primary tumor only- NOT mets or recurrence; in the rare instance that the tumor extends contiguously to an adjacent site and tissue from the primary site is not available, code grade from the contiguous site

9. Rules for coding solid tumor 3) Code the grade (6 th digit) for specific histologic terms that imply a grade (i.e., undifferentiated sarcoma 8805/3 4 ) 4) For in situ or combined in situ/invasive tumors- if a grade is assigned for an in situ tumor, code it. Do NOT code grade for dysplasia. If there are both in situ and invasive components, code only the grade for the invasive portion, even if it is unknown

10. Rules for coding solid tumors 5) If more than one grade is given, code the highest grade, even if it is only a focus. Code grade in the following priority order using the first applicable system: a) Special grade system for the sites listed in #6 b) Differentiation, using instructions in #7 (2, 3, or 4 grade system) c) Nuclear grade, using instructions in #7 (2, 3, or 4 grade system) d) If it isn’t clear whether the grade assigned is differentiation or nuclear, but a 2, 3, or 4 grade system was used, code it using instructions in #7 e) Terminology

11. Rules for coding solid tumors 6) Use information from the special grade system first; if no special grade can be coded, go on to #7 Grade information based on CS SSF’s for breast, prostate, heart, mediastinum, peritoneum, retroperitoneum, soft tissue, and kidney parenchyma is used to code grade

12. Rules for coding solid tumors See the rules for each of these SSF’s for details on how to code grade for these sites: CS Schema Special grade system Breast Nottingham or Bloom-Richardson (BR) Score/Grade (SSF7) Prostate Gleason's Score on Needle Core Biopsy/Transurethral Resection of Prostate (TURP) (SSF 8) Prostate Gleason's Score on Prostatectomy/Autopsy (SSF 10) Heart, Mediastinum Grade for Sarcomas (SSF 1) Peritoneum Grade for Sarcomas (SSF 1) Retroperitoneum Grade for Sarcomas (SSF 1) Soft Tissue Grade for Sarcomas (SSF 1) Kidney Parenchyma Fuhrman Nuclear Grade (SSF 6)

13. Rules for coding solid tumors 7) Use the two, three, or four grade system information Two grade system Term Description Grade Code Exception for Breast and Prostate Grade Code 1/2, I/IILow grade2 1 2/2, II/IIHigh grade4 3

14. Rules for coding solid tumors Three grade system Term Description Grade Code Exception for Breast and Prostate Grade Code 1/3Low grade21 2/3Intermediate grade32 3/3High grade43

15. Rules for coding solid tumors Four grade system Term Description Grade Code 1/4Grade I; Well differentiated1 2/4Grade II; Moderately differentiated2 3/4Grade III; Poorly differentiated3 4/4Grade IV; Undifferentiated4

16. Rules for coding solid tumors 8) When coding grade from terminology, use the “description” column or the “grade” column. Breast and prostate use the same grade code with a few noted exceptions.

17. Rules for coding solid tumors Description Grade Assign Grade Code Exception for Breast and Prostate Grade Code Differentiated, NOSI1 Well differentiatedI1 Only stated as ‘Grade I’I1 Fairly well differentiatedII2 Intermediate differentiationII2 Low gradeI-II21 Mid differentiatedII2 Moderately differentiatedII2 Moderately well differentiatedII2 Partially differentiatedII2 Partially well differentiatedI-II21 Relatively or generally well differentiated II 2 Only stated as ‘Grade II’II2

18. Rules for coding solid tumors Description Grade Assign Grade Code Exception for Breast and Prostate Grade Code Medium grade, intermediate grade II-III 3 2 Moderately poorly differentiated III 3 Moderately undifferentiatedIII3 Poorly differentiatedIII3 Relatively poorly differentiatedIII3 Relatively undifferentiatedIII3 Slightly differentiatedIII3 DedifferentiatedIII3 Only stated as ‘Grade III’III3 High gradeIII-IV43 Undifferentiated, anaplastic, not differentiated IV 4 Only stated as ‘Grade IV’IV4 Non-high grade 9

19. Rules for coding solid tumors 9) If no description fits or grade is unknown prior to neoadjuvant therapy, use code 9 (unknown)

20. Special grade system rules  Breast uses Bloom Richardson (BR) or Nottingham  Coded in SSF7  Code in priority order a) BR scores 3-9 b) BR grade (low, intermediate, high)

21. Special grade systems rules  BR score is expressed as a range, 3-9.  Based on three morphologic features: degree of tubule formation/histologic grade, mitotic activity, nuclear pleomorphism/nuclear grade of tumor cells

22. Special grade system rules  If a pathology report uses words such as low, intermediate, or high rather than numbers, use this table to code grade Description CS Code Grade Code Score of 30301 Score of 40401 Score of 50501 Score of 60602 Score of 70702 Score of 80803 Score of 90903 Low Grade, Bloom-Richardson (BR) grade 1, score not given1101 Medium (Intermediate) Grade, BR grade 2, score not given1202 High Grade, BR grade 3, score not given1303

23. Special grade system rules  If only a grade of 1 through 4 is given with no information on the score, and it is unclear if it is a Nottingham or BR grade, do not use the conversion table.  Instead, continue on to #7 in the grading rules  If multiple scores are reported, code the highest score

24. Special grade system rules  Kidney uses Fuhrman nuclear grade  Parenchyma ONLY- not renal pelvis!  Coded in SSF6  Fuhrman nuclear grade is a four-grade system based on nuclear diameter and shape, the prominence of nucleoli, and the presence of chromatin clumping

25. Special grade system rules DescriptionCS Code Grade Code Grade 10101 Grade 20202 Grade 30303 Grade 40404

26. Special grade system rules  Soft tissue sarcoma uses a three-grade system  French Federation of Cancer Centers Sarcoma Group (FNCLCC)  Coded in SSF1  In some cases (especially for needle bxs), grade may be specified only as “high grade” or “low grade”  Numeric grade take precedence over high or low

27. Special grade system rules DescriptionCS Code Grade Code Specified as Grade 1 [of 3]0102 Specified as Grade 2 [of 3]0203 Specified as Grade 3 [of 3]0304 Grade stated as low grade, NOS1002 Grade stated as high grade, NOS2004

28. Special grade system rules  Prostate uses Gleason grade  Coded in SSF8 (bx/TURP) and SSF10 (prostatectomy/autopsy)  Gleason grade is based on a 5-component system and generally shows two main histology patterns

29. Special grade system rules  The primary pattern occupies >50% of the cancer  It is usually the first number of the Gleason grade  Secondary pattern is indicated by the second number  These two numbers are added together to create the score, ranging from 2-10

30. Special grade system rules  If there are two numbers, assume they refer to patterns, and add them together to obtain the score  If only one number is given, and it is < 5, and not specified as a score, do not use the information, because it could refer to either a score or a grade  If only one number is given, and it is >5, assume that is the score and use it

31. Special grade system rules Change in prostate grading Gleason Description SEER SEER score CS Code Grade Code AJCC 7th 2003- 2013 AJCC 6th prior 2003 20021 G1 30031 G1 40041 G1 50051 G1 G2 60061 G1 G2 70072 G2 G3 G2 80083 G3 90093 G3 100103 G3

32. Special grade system rules  Due to these changes, analysis of prostate grade for cases diagnosed prior to 2014 based solely on the grade field is not recommended

33. Special grade system rules SSF 8 Code SSF 10 Grade Code 002003004005006007008009010988998999 002111112333*11 003111112333*11 004111112333*11 005111112333*11 006111112333*11 007222222333*22 008333333333*33 009333333333*33 010333333333*33 988************ 998111112333*** 999111112333***

34. Changes in coding grade  The new grading instructions can be found at http://seer.cancer.gov/tools/grade/  CoC and SEER will incorporate these instructions in their respective coding manual for 2014  KCR Abstractor’s Manual will be updated

35. Changes in coding grade  Questions?