Common Abstracting Errors: A Journey Through The Abstract Thru The... · 2019. 12. 6. · Journey...

Common Abstracting Errors: A Journey Through The Abstract

Kimberly DeWolfe, MS, CTR

GATRA Fall Education Conference

November 6, 2019

CONFIDENTIAL 2 © 2018 himagine solutions inc.

Journey through the abstract from Demographics to Follow-up

Share tips for avoiding common errors along the way

Try to stay sane and positive

Objectives


Surveillance vs. Health care

Balancing the two in the cancer registry world is a challenge for the standard setters

Keeping The Cancer Registry Field Relevant and Current

Demographics Avoiding Unknown Codes


Look for a picture of the patient in the EMR ● Profile pictures are starting to show up in my

facility’s record

Try to Avoid Unknown Race for Hispanic Patients

● Consult SEER’s Appendix D

https://seer.cancer.gov/manuals/2018/SPCSM_2018_AppendixD.pdf

Race and Ethnicity




SEER Appendix D Excerpt


Leave no stone unturned when looking for SS# ● There may be a place its hidden you are

unaware of

You just need to ask!

Note: Medicare Beneficiary ID will be required by NAACCR starting 1/1/2020, and it has the potential to replace the SS# requirement

Ask EMR Experts for Help to Find Elusive Fields like SS#

Primary Site and Histology Coding


Hold on tight! Here we go!


Primary Site Priority Rules

When conflicting information, consult priority rules in Solid Tumor Manual or MP/H Manual ● Set of rules depends on date of diagnosis and if 2018

manual updated that particular site

Still uncertain? ● Consult SEER Inquiry and/or SEER Appendix C


Path report does not take priority when assigning primary site code for:

● Colorectal (Surgical Operative Report)

● Head and Neck (Tumor Board)

● Lung – Bronchus C340 not always mainstem bronchus

o code to upper lobe when only referred to as bronchus

● Urinary Sites – You may need to assign C689 when multiple urinary organs are involved at diagnosis

Tricky Primary Sites


If multiple organs and lymph node chains involved at diagnosis in certain lymphoma patients, you assign C80.9

● Page 48 of Hematopoietic and Lymphoid Neoplasm Coding Manual o Rule PH27 in Module 7

● Hodgkin and Non-Hodgkin histologies

Lymphoma with Multiple Organs Involved at Diagnosis


Be sure you have a valid primary site for the histology you assign

● These two fields along with schema discriminators drive the AJCC ID and the TNM staging schemas

● If your software doesn’t allow you to stage a case, this is sometimes a red flag to you o Something could be amiss

o However, the new solid tumor manual warns you not to change a site or histology to make something stageable

● It really could be correct as is

Site/Histology Validity


2018 Solid Tumor Rules or MP/H Rules

Applicable Chapter in AJCC TNM 8th Edition ● Is there an applicable stage grouping for that

combination?

● Is the histology you assigned listed in the beginning of the chapter?

SEER’s Site/Histology Validity List

Your Go To Resources for Site/Histology Validation


Pathology from FNA of right neck mass: Metastatic Squamous Cell Carcinoma. Pathology from Right Tonsil Biopsy: Keratinizing Squamous Cell Carcinoma, p16 by IHC positive

What is the correct histology? ● 8071.3 Keratinizing Squamous Cell Carcinoma

● 8085.3 Squamous Cell Carcinoma, HPV positive

● 8070.3 Squamous Cell Carcinoma

8071.3 Keratinizing Squamous Cell Carcinoma

Pop Quiz #1


Head and Neck Solid Tumor Rules 2018: July 2019 Update


Incorrectly using 8085 & 8086 fields when the only lab test done is p16 IHC study

Altering the histology so the case can be AJCC staged ● If the pathologist states Keratinizing SCCA, code to 8071

Incorrectly interpreting an In Situ Hybridization as an IHC test instead of an ISH test

● Example: In situ Hybridization Probe Stain Summary Immunostains for high risk (HPV 16/18) and low risk (HPV 6/11) human papillomavirus was performed. The high risk HPV stain is positive. The low risk stain is negative. (this case would be coded to 8085)

Frequent Oropharyngeal Ca Errors

Source: the latest himagine Tumor tip inspired by a case I had a question about

Lymph-Vascular Invasion


Assigning code 9 for any insitu behavior ● Use code 0 for any insitu tumor

Assigning code 9 when angiolymphatic invasion is stated to be present or not present.

● used in the breast cancer surgical pathology report

● Angiolymphatic invasion is a synonym for LVI

Common Lymph-Vascular Invasion Errors


Follow the coding instructions in SEER or STORE for coding LVI in the neoadjuvant setting

● Consult the chart provided in either manual

LVI seems to be the most common field coded to 9 regardless of what the abstractor enters in the pathology text section

● Path text: LVI: present

● LVI Code: 9/Unknown

Lymph-Vascular Invasion in the Neoadjuvant Setting and 9/Unknown

Tumor Size Summary


Priority Rules apply here too

In Neoadjuvant Setting ● Use the largest clinical size

Be aware of the rounding and ambiguous size rules in STORE

Use the largest size Documented Before Treatment


Reporting the size from the breast core biopsy path specimen

Reporting the size from the neoadjuvant surgical pathology specimen

Not following the priority rules in STORE in the neoadjuvant or nonsurgical setting

● Review the entire record

● Don’t go directly to imaging studies

1. Op note

2. Physical Exam

Common Tumor Size Summary Errors


Priority Order

Source for Tumor Size Summary from the Surgical Pathology Report

1 CAP Protocol aka Synoptic Report

2 Final Diagnosis

3 Microscopic

4 Gross Examination

5 If no tumor size reported in path report, but the surgeon notes a tumor size in the operative report, use the tumor size stated by the surgeon

Priority Order for Tumor Size Summary In The Surgical Resection Setting NO neoadjuvant therapy given

Note 1: If the path report is without a CAP protocol check list, use the headings listed in items 2-4 (in that order) Note 2: The path specimen should not be from a biopsy. You should have at least an excisional biopsy

Source: 2018 STORE Manual as of July 2019


Priority Order Source for Tumor Size Summary Examples

1 Physical Exam PE: 2.5 cm. Imaging: 2.8 cm. Tumor size summary is 025

2* Imaging No size on PE. CT size stated as 3.4 cm. Tumor size summary is 034

3 Other diagnostic procedure prior to any other form of treatment

No size on PE. No size on imaging studies. Tumor size stated on Cystoscopy for bladder cancer as 4 mm. Tumor size summary is 004.

Priority Order for Tumor Size Summary The Non-Surgical Setting No surgery and/or neoadjuvant therapy patient

*If two different radiographic studies have discrepancies, code the largest size among the available imaging studies unless the physician specifies otherwise

Source: 2018 STORE Manual as of July 2019

STORE Note 3 States: If no surgical resection, then largest measurement of the tumor from physical exam, imaging, or other diagnostic procedures prior to any other form of treatment.


Scenario Directive Examples

Tumor size reported as < x mm OR < x cm

Tumor size should be 1 mm less • If tumor size is reported as < 4mm, code size to 3mm

• If tumor size is reported < 4cm, code size as 039

Tumor size reported as > x mm OR > x cm

Tumor size should be 1 mm more • If tumor size reported > 10 mm, code as 011

• If tumor size reported as > 5 cm, code as 051

Tumor size reported to be between two sizes

Tumor size should be the midpoint between the two or between the range

• Between 2 and 3 cm, code as 025

Rounding with tenths of millimeter values

• Round up when described as < x mm

• Round down when described in the 1-4 range mm range

• Round up when described in the 5-9 range

• If the largest dimension of tumor is < 1 mm, record size as 001 (seen often in micro-nvasive breast cancer)

• Cancer in polyp described as 2.3 mm, round down to 002

• Breast cancer described as 5.7mm invasive tumor, round up to 006

Rounding Rules for Tumor Size Summary

Source: 2018 STORE Manual as of July 2019 and AJCC TNM 8th Edition

Lymph Node Procedures


Did you know? ● If a sentinel lymph node and regional lymph node dissection are

performed on the same day, # sentinel lymph nodes positive = 97

● Record the total # positive regional lymph nodes (both sentinel and regional) in Regional Lymph Nodes Positive

[Source: page 163 STORE 2018 Manual, bullet #5]

Note: The 97 rule only applies to breast cancer patients

Breast Cancer Lymph Nodes Positive and Examined


Don’t rely on the path report to determine lymph node procedure type

Your first priority is the operative note

If an attempt at SLND was done but path report renders no lymph node material, you still assign Scope of Regional Lymph Node Code 2 (Sentinel LND Bx)

If some of the lymph nodes in path specimen are blue with dye and some are not, you still consider them all sentinel lymph nodes

Code Intent for Lymph Node Procedures


Do NOT code any form of lymph node biopsy in the Surgical Diagnostic and Staging Procedure section

● AKA biopsy

Do code Scope of Regional Lymph Nodes to appropriate code (1, 2, etc) regardless if the pathology is positive or negative for malignancy.

● Your primary site surgery code will be 00 in this scenario

Common Lymph Node Procedure Error


STORE and SEER consider a lymph node sampling of any kind a surgical procedure

This means: If it is the first procedure prior to primary site, it is your Date of First Course of Treatment

SEER’s definition of a surgical procedure makes the most sense to me

Coding +/- Cytology of LN


Surgical procedure = Any surgical procedure coded in the fields Surgery of Primary Site, Scope of Regional Lymph Node Surgery, or Surgery of Other Regional or Distant Site

Source: SEER Program Coding and Staging Manual 2018, p. 149

SEER Definition of Surgical Procedure


3/4/18 FNA of an inguinal lymph node is positive for Diffuse Large B-Cell Lymphoma

3/21/18 Chemotherapy started

How do you code the 3/4/18 Procedure? ● Code Scope of Regional Lymph nodes to 1 (Bx or

Aspiration LN)

What is the Date of 1st Course Treatment? ● 3/4/18

Pop Quiz #2

AJCC TNM 8th Edition Staging


If no DRE information available, the Clinical T cannot be coded as T1c

AJCC 8th Edition Chapter 58 Prostate Rule for Clinical Classification

o DRE of the prostate is the primary clinical assessment. Neither imaging nor tumor laterality from the prostate biopsy should be used for clinical staging.

Clinical T for Prostate

Source: himagine Tumor Tip from QA Department


48 yo male with rising PSA from 4.04 to 5.9. MRI of prostate revealed single nodule within the right prostate; no evidence of extraprostatic extension. He refused DRE. Prostate needle biopsy path: Adenocarcinoma in 1 core on the right corresponding with MRI findings. All other core bxs negative.

What is the correct cT?

● Blank

Pop Quiz #3


When TURB is the only procedure for a bladder cancer

● Pathological TNM are blank with stage group 99

You can only clinically stage the patient

Pathological Stage for Bladder TURB Patient


Most Testis patients will not have a clinical stage, especially cT

If there is no biopsy, then you cannot clinically stage the patient

The primary is rarely biopsied http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/male-genital-organs-chapters-57-59/testis-chapter-59/91555-clinical-stage-for-testis

Clinical Stage for Testis

http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/male-genital-organs-chapters-57-59/testis-chapter-59/91555-clinical-stage-for-testis
































You are allowed to assign a clinical T, N and/or M in the pathological TNM column for stage IV lung cancer patients

Source: AJCC TNM 8th Edition Chapter I – Principles of Cancer Staging

● A patient may be staged as both clinical and pathological stage IV if there is confirmatory microscopic evidence of a distant metastatic site during the diagnostic workup, which is categorized as pM1 and T and N may be categorized only clinically.

Pathological TNM for Stage IV Lung Cancer Patients


7/12/18 Left upper lobe mass biopsy: Pulmonary Adenocarcinoma

7/23/18 Left pleural fluid: Metastatic Adenocarinoma consistent with patient’s known lung primary

7/24/18 PET/CT: Left hilar process with direct invasion of mediastinum with multiple mediastinal foci of metastatic disease. Extensive pleural metastatic disease. Right upper paratracheal lymph node probably metastatic

Treatment: Pleurx catheter insertion and chemotherapy

What is the correct path TNM stage? ● cT4 cN3 pM1a Stage group 4A

Pop Quiz #4

Treatment Common Errors


Controls symptoms to alleviate pain or make patient comfortable

May include first course surgery, radiation, systemic therapy and/or other pain management therapy.

You will need to double code first course treatments that are surgery, radiation or systemic

● Example: a patient with metastatic small cell lung cancer to the spine receives radiation to the spine to shrink the tumor and eliminate stenosis and nerve impingement

o Since the radiation acts to kill cancer cells, it is coded as first course radiation in conjunction with palliative treatment

Palliative Care not Coded

Follow-up Common Errors


Prone to registrar fatigue ● One of the last few screens in your software program to

complete

● Don’t succumb or check your abstract the next day

Disease Status assigned as 1/NED without a physician statement and/or in the setting of higher stage disease

Follow-up Data Items


Provided a summary of some of the common abstracting errors encountered in the last few months as an abstractor

Shared tips and pop quizes inspired by the himagine QA department

I hope you find this useful!

Summary and Conclusion


Questions ?


AJCC Cancer Staging Manual, 8th Edition

Solid Tumor Rules 2018; NCI: SEER; Updated July 2019.

Standards for Oncology Registry Entry (STORE), 2018, American College of Surgeons, Commission on Cancer, Version 1.0

CAnswer Forum, American College of Surgeon’s, Commission on Cancer, http://cancerbulletin.facs.org/forums/

NAACCR Webinar Series 2018-2019: Coding Pitfalls, 9/5/19, guest speakers Karen Mace, CTR and Janet Vogel, CTR

Janet Vogel, CTR, himagine QA specialist and educator

References Used

http://cancerbulletin.facs.org/forums/


Neurofibromatosis is a genetic syndrome and not a reportable neoplasm

What is the 2018 Solid Tumor Manual: Malignant CNS Section, p. 4

Jeopardy Question: Name that Manual


Another term for Lymph-Vascular Invasion commonly used in breast cancer patients

Angiolymphatic Invasion

Jeopardy Question: Synonyms


Ovarian Mucinous Borderline Tumor, Intestinal Type with Microinvasion

Not Reportable: SEER Inquiry Q&A 20170043

Jeopardy Question: Reportable or Not Reportable?


Stage 0 DCIS Breast Cancer Patient’s Surgical Path Report does not mention the LVI status

What is the correct code for LVI?

9/Unknown

0/No Lymphovascular invasion stated as Not Present

Jeopardy Question: Lymph Vascular Invasion


Stage IV Lung Cancer Patient with no surgical resection, just a biopsy proven Adenocarcinoma of the primary and positive metastatic adenocarcinoma cells in pleural fluid

PET/CT reveals N3 paratracheal lymph node disease and confirms pleural effusion and T4 tumor

What is the correct path TNM?

● pT blank pN blank pM1a

● cT4 cN3 pM1a

Jeopardy Question: Stage That Tumor


GIST Tumor with lymph node mets but not stated by pathologist as malignant

Reportable or Not Reportable?

Reportable ● Source: page 15 STORE 2018 Manual

Jeopardy Question: Reportable or Not Reportable?


A lymph node biopsy is coded as a surgical procedure

True

True or False?


If a sentinel lymph node and regional lymph node dissection are performed on the same day and 3 sentinel lymph nodes are positive, the # sentinel lymph nodes positive is?

97

OR

3

Sentinel Lymph Node Biopsy

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