Monthly Coding Quality Tips

UCR Quality Tips

Please note:  the information in these Quality Tips was accurate according to standard setter coding guidelines in effect at the time the Tips were released; however, guidelines continue to change and evolve as rules are clarified or updated.  Please use caution and verify all past Quality Tip information against current coding guidelines.

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    Q-Tips 2024
          September - Other Sites - Histology Coding

      Other Sites Solid Tumor Rules:  HISTOLOGY CODING HIGHLIGHTS

      The Other Sites module of the SEER Solid Tumor manual applies to all primary sites excluding Head & Neck, Colon, Lung, Breast, Cutaneous Melanoma, Kidney, Urinary and CNS, and should be used for cases diagnosed 1/1/2023 and forward.  It contains 21 site specific histology tables, which were created in place of adding numerous site-based histology (“H”) rules. Here are a few important notes to remember:

      • Some of the histology tables include important site-specific coding tips in the notes preceding the actual codes; it is imperative to refer to these to determine if there are additional coding instructions or criteria that must be met to assign the correct histology code.
      • Not all sites or histologies are included in the tables, or in the H rules, so in some cases registrars may need to use ICD-O-3 and its updates to code the histology correctly (see References section below).             
      • The priority is generally to code the most specific histology, but the Other Sites Solid Tumor guidelines should be applied in the following order:
        • Priority Order for Using Documents to Identify Histology, THEN
        • The “Coding Histology” instructions AND
        • Histology (H) Rules in conjunction with Site-Specific Histology Tables 3-23
        • If needed:
          • ICD-O-3 and its updates -- when instructed by the H rules or site-specific tables, or if the code cannot be determined from prior steps.
          • If still unable to arrive at the correct code, submit a question to Ask A SEER Registrar (https://seer.cancer.gov/registrars/contact.html)

      CODING EXAMPLES

      • A patient underwent a 10/5/2023 CT of the abdomen/pelvis which revealed a 3.1 cm liver lesion arising from the intrahepatic bile duct and showing mild peripheral duct dilation, most likely a cholangiocarcinoma.  The patient then had a wedge biopsy of the liver performed with a diagnosis of adenocarcinoma. 
        • Histology should be coded 8160/3, per Table 9a - Guidelines for Assigning Primary Site for Liver and Intrahepatic Bile Duct.  The notes preceding this table indicate that adenocarcinoma (8140/3) with primary site of liver (C220) is biologically impossible.  
        • The table indicates that for this case, the combination of a liver biopsy showing adenocarcinoma with a supporting scan stating the tumor was arising from the intrahepatic bile duct, results in C221 and 8160/3 as the correct site and histology.
      • Workup and biopsy on 2/21/2024 showed a mass in the pancreas diagnostic of pancreatic intraepithelial neoplasia III (PanIN).
        • Histology should be coded 8148/2.  Rule H2 (single histology) could apply, per Note 2:  use Tables 3-23 to code histology.  Table 11 - Pancreas Histologies shows that PanIN is a synonym for code 8148/2. 
        • Since Table 11 doesn’t specifically list “PanIN III”, if users opted to continue through the rules, H4 would confirm the correct code is 8148/2 - PanIN III is one of the histology examples listed under this rule. 
      • Pathology report of the left ovary on 5/15/2024 revealed a diagnosis of malignant mixed mullerian tumor (MMMT) along with features of sarcoma.
        • "Features of sarcoma” is ignored per Coding Histology instruction #2 - code the histology described as features/features of ONLY when there is a specific ICD-O code for the “NOS with ____ features”.  There is no such applicable code for this case.
        • Histology should be coded 8980/3, per Rule H12 (single histology, MMMT) and Table 13 - Ovary Histologies, which indicates that Malignant Mixed Mullerian Tumor is now a synonym for code 8980/3 Carcinosarcoma.

      Key Points:  Users of the Other Sites Solid Tumor guidelines must be familiar with all sections including Coding Histology instructions and coding notes in site-specific tables.  The guidelines refer to ICD-O in lieu of ICD-O-3; the version is not specific so it can permit updates.  Abstractors need to make sure to use the currently approved version of ICD-O, when needed (see References section below).  And remember to use the 2023 Other Sites STRs and Solid Tumor General Instructions for tumors diagnosed 01/01/2023 and later.  For Other Sites tumors diagnosed 01/01/2007 through 12/21/2022, use the 2007 Multiple Primary & Histology (MPH) Rules and General Instructions.

      BONUS MINI-TIP/Reminder: The 2007 MPH Rules previously instructed users to “Code the histology from the most representative specimen.”  Now, the 2023 Other Sites Solid Tumor Rules instruct to “Code the most specific histology from biopsy or resection. When there is a discrepancy between the biopsy and resection (two distinctly different histologies), code the histology from the most representative specimen (the greater amount of tumor).”  

      References

          August - Mets at Dx - Special Considerations

      Special Considerations for METS AT DIAGNOSIS Data Items

      Reminders for all Mets at Dx items:  (not a complete list of coding instructions, which can be found in the SEER manual - see References section below)  

      • Code 0 (no mets) when distant metastases are documented, but the organ associated with the Mets at Dx data item is not mentioned as an involved site. 
        • For example, scans show metastases to distant lymph nodes, liver, and adrenal glands.  There is no imaging of the brain to determine whether or not there may be brain mets.  Code Mets at Dx – Brain as 0.
        • Imaging or sampling of the associated organ is NOT required to assign 0 in any of the Mets at Diagnosis data items; they may be assumed negative unless stated otherwise.
      • Use code 9 only when there are known distant metastases, but it is not known if the organs associated with the Mets at Dx data items are involved.  
        • For example, a patient diagnosed and treated elsewhere years ago with kidney cancer is stated to have been “Stage IV” NOS at diagnosis, with no specific sites of metastasis documented.  Code all of the Mets at Dx fields to 9.
      • Code 1 in any of these data items if they’re specifically mentioned as distant metastatic sites for an unknown primary cancer (C809).
      •  
      • Mets at Dx – Bone
        • Use code 1 when bone is the primary site and there are metastases in a different bone or bones; do not assign code 1 for multifocal bone involvement of the same bone.
        • Bone marrow involvement is not coded in this data item; code in Mets at Dx – Other.
      • Mets at Dx – Lung
        • Pleura/pleural nodules or pleural fluid involvement are not coded in this data item; code in Mets at Dx – Other.
        • Lung metastases from a primary tumor in the contralateral lung are coded in this data item; do not assign code 1 for multifocal involvement of the same lung as the primary tumor.
      • Mets at Dx – Distant Lymph Nodes 
        • Assign code 0 for unknown primaries with lymph node involvement, unless stated to be distant lymph nodes.
        • Use code 0 when lymph nodes are documented as involved, but there is no indication whether they are regional or distant.  
          • For example, a prostate case that was diagnosed elsewhere and only stated to have nodal mets NOS. 
        • Whether a lymph node is considered regional or distant for this data item is determined by its classification in the AJCC TNM staging system, not the SEER Summary Stage or Extent of Disease systems.
        • Use code 8 (not applicable) for cases with primary site C770-C779.  Use code 0 or 1 for lymphomas of extra-nodal sites (see Coding Examples and References below).
        • Placental lymph node involvement for placental primaries is classified as distant lymph node involvement (M1) and recorded in this data item.
      • Mets at Dx – Other
        • This data item is the only one with a special code 2, for carcinomatosis. 
          • If a patient has metastatic disease to a site other than bone, brain, liver, lung or distant nodes AND carcinomatosis, assign code 2 for carcinomatosis. Code 2 takes priority.
        • Sites of metastasis coded in this item include, but are not limited to, bone marrow, pleura, and malignant pleural effusion.
        • Use code 1 for bone marrow involvement by Stage IV lymphomas; EXCEPT lymphomas/leukemias with primary site of C421 (bone marrow) – these are coded 8, not applicable.

      CODING EXAMPLES

      • Patient recently diagnosed with high grade colon adenocarcinoma has imaging showing hepatic masses that are probable metastases, pleural effusion at left lung base, and peritoneal nodules indicative of carcinomatosis.  Pleural effusion cytology returns showing malignant cells, consistent with adenocarcinoma of colorectal origin.
      • Mets at Dx items would all be coded 0, except:
        • Mets at Dx—Liver = 1
        • Mets at DX—Other = 2, for the carcinomatosis.  Although the malignant pleural effusion would be coded as 1 in this data item, the additional presence of carcinomatosis takes priority.  
          • Note that pleural effusion is NOT coded in the Mets at Dx—Lung data item.
      • Patient presents with a right groin mass; PET CT shows large right inguinal lymph nodes, very hypermetabolic; several axillary nodes with milder but still increased activity; and diffuse marrow uptake; all findings suspicious for lymphoma.  No other abnormalities noted.  Pathology from excisional biopsy of the groin mass showed diffuse large B-cell lymphoma (DLBCL) of inguinal lymph nodes, and bone marrow biopsy confirmed involvement by DLBCL.
      • Mets at Dx items would all be coded 0, except:
        • Mets at Dx—Other = 1, for bone marrow involvement.  Note that this is NOT coded in the Mets at Dx—Bone data item.
        • Mets at Dx—Distant Lymph Nodes = 8, the default code for C77._ lymphomas.  
          • Even though the involved inguinal and axillary nodes are widely distant from each other, this would be captured in the extent of primary tumor items, not Mets at Dx, for a C77._ lymphoma.  
          • Any other code, including 0, in Mets at Dx--Distant LNs will fail a standard NAACCR edit.  8 is the required code for C77._
      • MRI for facial numbness showed a well-circumscribed soft tissue mass in the upper right nasal cavity.  Biopsy of this mass showed Extra-nodal NK/T-cell lymphoma, nasal type.  Subsequent staging PET scan found intense uptake in nasal passage tissues, plus hypermetabolic upper jugular and duodenal lymph nodes, and multifocal nodular metastases in liver; all consistent with the reported history of lymphoma; no other sites of disease involvement.  Bone marrow biopsy was negative.
        • Primary site would be coded C300 (nasal cavity), per Hematopoietic Manual rule PH25, notes 1 & 3:  extra-nodal site with regional (upper jugular) nodes; distant node and liver involvement captured in staging items.
        • Mets at Dx items would all be coded 0, except:
          • Mets at Dx—Liver = 1.  
          • Mets at Dx—Distant Lymph Nodes = 1 (duodenal nodes).  Because this is not a C77._ lymphoma, it is permitted to code distant nodal mets in this data item; if none were present, it would be coded 0 (not 8, as required for C77._).
            • Note:  use caution when lymph nodes in multiple areas are involved; in some cases, these could change the primary site to C77._; carefully follow the rules in the Hematopoietic manual.

      Key Points:  Some of the Mets at Diagnosis data items contain special instructions for different types of metastases, or different primary sites/schemas.  Be careful not to automatically assign a 1 for mets in associated tissues that are not the actual organ named in the data item; and remember the unique code 2 for carcinomatosis in the Mets at Dx – Other item.  In addition, check the inter-field edits when coding these items for lymphomas, as allowable codes differ by primary site.

      References

      2024 SEER Program Coding and Staging Manual, Section IV – Stage Related Data Items; Mets at Diagnosis items.  https://seer.cancer.gov/manuals/2024/SPCSM_2024_MainDoc.pdf 

      SEER Hematopoietic Manual, module 7 – coding primary site.  https://seer.cancer.gov/tools/heme/Hematopoietic_Instructions_and_Rules.pdf 

      SEER Inquiry System (SINQ), inquiry number 20210017 

          July - Address at Diagnosis

      Below is an updated refresher on Address at Diagnosis, including some hints on how to code unusual residence situations.  Since Utah serves as a regional health care hub for rural communities in surrounding states, we often see issues with address.

      RESIDENCE/ADDRESS AT DIAGNOSIS 

      Coding the correct address at diagnosis is vital when submitting cases to central cancer registries.  In addition, Address at Diagnosis data items are required by the ACOS Commission on Cancer (CoC).  Some reasons include:

      • Avoiding duplicate reporting/over-counting of the same cancer case by multiple central and hospital registries to national databases, when patients receive care in multiple states.
        • Only patients who are state residents at diagnosis are to be reported by that state’s registry to NCI-SEER and CDC-NPCR.  
        • Central registries send cases for out-of-state residents to the other state’s registry; in some instances, this may be the only way a case is reported to that state.
      • Providing more accurate data for studies that use address as indicators of socioeconomic status, access to care, and frequency of cancers by geographic area (“cancer clusters”).  
        • Note:  A physical street address, if available, is preferred over a post office box as a truer representation of patients’ immediate living environment.
        • The PO Box should be entered in the “Address at DX—Supplemental” field (NAACCR item #2335). 

      Some guidelines in the SEER and STORE Manuals for unusual address scenarios seen at UCR include the following.  Please see additional details in the References section below.

      • For patients with more than one residence (e.g., snowbirds or people with second homes), code the address where the patient spends the majority of their time; if that information is unavailable, code the residence the patient specifies at time of diagnosis.
      • For homeless patients, code the address of the shelter where the patient is staying, if applicable; if not, code the address of the diagnosing hospital.  Document the source of the address in the abstract text.
      • Code a patient’s usual (home) residence rather than a temporary local address.  
        • Examples include patients temporarily residing with family during cancer treatment, migrant workers, and educators temporarily assigned to a local university.
      • For college students, code the residence where the student is living while attending college.
        • UCR also applies this guideline to code the residence where a patient is living while serving a church or religious mission.
      • Code the physical address (not the PO Box) of the institution for patients living in institutions, such as prisons, nursing homes, and mental or physical care facilities. 

      Coding Examples

      • 49 year old female presents with a history of breast cancer in December of 2020, status post lumpectomy, radiation and hormone treatment.  She arrives at the Utah reporting hospital in April 2024 for continuation of care and ongoing hormone therapy, planned for a total of 10 years.  The Utah hospital’s oncologist renews her prescription for tamoxifen.  The location of her original diagnosis and treatment is not stated in physician notes, and no records from other facilities are found in the EMR.  A question submitted to the UCR Inquiry System reveals no prior records for this patient in UCR’s database.  
        • Address at Diagnosis would be coded as Street - Unknown, City - Unknown, ZZ, 99999.  It would be unlikely that the patient’s current Utah address was the same at diagnosis, since she had extensive treatment and was not on the Utah state registry.  The failed efforts to find patient’s original address should be documented in abstract text fields.
        • Ideally, Current Address data items would also be substantiated by abstract text indicating when patient moved to Utah, or at least confirming that patient now resides in Utah.
      • UCR receives an abstract from a Utah hospital documenting that a patient had December 2023 scans in Texas showing enlarged lymph nodes NOS, then a biopsy at the Utah hospital in January 2024 which diagnosed classic Hodgkin lymphoma; it states the Utah hospital initiated chemotherapy on February 2, 2024.  An Address at Diagnosis in Texas is coded on their abstract, with Current Address coded as Utah.  Later, the Texas state cancer registry sends UCR an abstract for the same case, but codes the same Utah address in Address at Diagnosis, and a different Texas address as the Current Address.  They also mention chemo given in Texas starting February 19, 2024.  Neither abstract documents anything about residence in their text.
        • From this information, UCR would be unable to confidently determine the correct state of residence at diagnosis, and therefore whether or not this case should be included in Utah’s data submissions to SEER and NPCR.  
        • We would be forced to follow back to the facilities for address confirmation.

      Key Points:  Most cancer registry software allows copying between the Current Address and Address at Diagnosis fields; however, it’s important to take a quick glance at admits and physician notes from both time periods to ensure the address has remained the same.  Good abstract text documentation of unusual residence situations can help avoid follow-back queries from UCR, such as noting in the PE or Remarks section that a patient resides in Utah but was diagnosed at an out-of-state facility while visiting family; or that the patient was living in rural Idaho at diagnosis, but moved to Utah a few months ago to pursue radiation treatments.

      References

      SEER Manual, https://seer.cancer.gov/tools/codingmanuals/ 

                  Section III Demographic Information – Place of Residence; Address at Diagnosis

      STORE Manual, https://www.facs.org/media/bfxlv0eu/store-manual-2024.pdf 

                  Section 1 – Patient Address and Residency Rules

      Please send any questions on the above Quality Tip through UCR’s Inquiry System at https://redcap01.brisc.utah.edu/ccts/redcap/surveys/?s=8KC7FP8XKN

       

          June - Converting Generic Terminology to Grade Codes

      Some schemas’ tables in the Grade Manual consist only of generic categories with the alphabetic codes A-D, and others include codes A-D for when the schema’s priority grade system was not documented.  For both of those types of schemas, abstractors can use the terminology conversion table in the Grade Manual to determine the correct code (see References section, below).  

      If the exact grade terminology documented on pathology reports isn’t listed in the schema’s standard code definitions, it’s important to check this table, as some of the term conversions may not be intuitive.  For example (not a complete list):

      • Differentiated, NOS = code A
      • Fairly well differentiated = code B
      • Partially differentiated = code B
      • Relatively or generally well differentiated = code B
      • Medium or intermediate grade = code C
      • Moderately or relatively undifferentiated = code C
      • Slightly differentiated = code C
      • Dedifferentiated = code C
      • Not differentiated = code D

      CAUTIONS:  

      • The above terms and the entire generic grade conversion table can ONLY be used for schemas that include the alpha grade codes A-D.  Furthermore, they are only to be used when no grade is stated from the schema’s preferred grading system (if applicable).  See Coding Examples below.
      • Do NOT use the terminology conversion table when a particular cancer’s schema assigns numeric codes to the generic grade descriptions.  For example Lung (schema 00360), in which “well differentiated” is coded 1.  This indicates that the site uses nuclear grading, for which the A-D codes are not appropriate, and therefore they’re not included on its grade tables.  

      In most cases, edits will catch generic grade codes when used incorrectly, but they should not be solely relied upon.

      CODING EXAMPLES

      • Incisional biopsy of an intranasal mass on 11/27/2023 was read as fairly well differentiated basaloid squamous cell carcinoma on pathology; procedure notes described the tumor as arising in the paranasal sinus (C31.9).  Patient was referred to an outside ENT surgical specialist for consultation, but no further information could be obtained.
        • Grade Clinical is coded B, since this case’s schema (Sinus Other – 00128) uses the generic A-D codes in its grade tables, and the terminology conversion table in the Grade Manual lists code B for “fairly well differentiated”.
        • Grade Pathological is coded 9 (unknown), because there is no information on whether definitive resection of the tumor was done.
      • 1/12/2024 right breast core biopsy showed Grade I ductal carcinoma in situ on pathology.  2/20/2024 path report from subsequent lumpectomy stated Intermediate grade ductal carcinoma in situ, margins widely negative.  
        • Grade Clinical is coded L, per the Breast schema’s Code L definition:  Nuclear Grade I (Low) (in situ only), and Coding Note 4 - Priority order for codes, In situ cancers: codes L, M, H take priority over A-D.
        • Grade Pathological is coded M - Nuclear Grade II (Intermediate) (in situ only).
          • Even though breast grade tables include the generic codes A-D, the generic grade terminology table would NOT be used to assign Clinical Grade A – “Only stated as Grade I” or Pathological Grade C – “Medium grade, intermediate grade”, because the pathologist’s stated grades can be found in the preferred/priority grading system descriptions for breast. 

      Key Points:  When pathology reports state the grade using only generic terminology, first determine whether this can be coded for the case’s schema -- i.e., the alpha codes A-D are included in the appropriate schema’s grade tables.  If the generic grade terms on the path report don’t exactly match the schema’s grade table descriptions, verify which code to assign from the terminology conversion chart in the Grade Manual.  Also check the schema’s Grade coding notes for any priority order stipulations of different grading systems.

      BONUS MINI-TIP/Reminder:  sometimes terms that sound like grade terminology might impact the histology code; for example, “poorly differentiated thyroid carcinoma” may be coded 8337 instead of 8010, according to the 2023+ Solid Tumor Other Sites guidelines.  Other examples are “well differentiated liposarcoma” 8851 and “moderately differentiated neuroendocrine carcinoma” 8249.  Always check the Solid Tumor Rules and ICD-O-3.2 Updates to verify when grade-associated histology terms may or may not be applicable for the primary site being abstracted, and review SINQ #20240022 for clarifications on how to interpret these terms in different sections of pathology reports.

      References

          May - Coding Histology for HPV-Related Cancers

      Greetings from the Utah Cancer Registry!  Our Quality Tip is a little different this month; we wanted to bring to your attention two recently published SINQs, which may help clear up some confusion about which years of diagnosis and primary sites apply to the p16/HPV-related histology codes.

      CODING HISTOLOGY FOR HPV-RELATED CANCERS

      Background:  Starting with diagnosis year 2021, sequential updates were made to registry coding guidelines for certain primary sites, to allow using results of the p16 immunohistochemical stain to code HPV-related histologies, such as 8085 and 8086.  Previously, these codes were only permitted when HPV status was determined by tests that directly detect the viral DNA or RNA, such as in situ hybridization (ISH) or polymerase chain reaction (PCR) testing.  There has been some confusion on when these updated guidelines allowing p16 results became effective pertaining to different primary sites and histologic subtypes.  Recently, these were clarified in the SEER Inquiry System (SINQ).

      Clarifications from SINQ -- Please click the inquiry number hyperlinks or search SINQ’s website in the References section below, to view the full questions including Discussion details.

      Solid Tumor Rules/Histology--Head and Neck, Other Sites: Please provide clarification about effective dates for using p16 testing to assign HPV-related histology codes for various primary sites. See Discussion.

      Answer:  Per 2024 Cancer PathCHART expert pathologist review, morphology codes 8085/3 and/or 8086/3 are valid and applicable to head and neck, oropharynx, cervix, vagina, vulva, fallopian tube, anus, and penis scrotum (reference: Cancer PathCHART: Product Downloads and Timelines). The Cancer PathCHART SMVL will be updated for C632, Scrotum, with the next release of the NAACCR Edits Metafile, currently scheduled for May 2024.

      Assign histology codes 8085 and 8086 for the sites listed in the Solid Tumor Rules histology tables. [Added font bolding for emphasis] The codes 8085 and 8086 are applicable for a small group of sites according to the year they became valid for implementation as follows.

      Head and Neck

      • Oropharynx, Base of Tongue, Tonsils, Adenoids (2022+)

      Other Sites

      • Cervix (2021+)
      • Anus (2023+)
      • Vagina (2023+)
      • Vulva (2023+)
      • Penis (2024+)
      • Scrotum (2024+)

      While ICD-O-3.2 and Cancer PathCHART list additional sites such as Accessory Sinuses, they have not yet been implemented in the U.S.

      Solid Tumor Rules/Histology--Head and Neck, Other Sites: Do human papilloma virus (HPV) histologies that occur with subtype/variants of squamous cell carcinoma (SCC) in various sites apply only to sites in Solid Tumor Rules, Head and Neck, Table 5 and Other Sites, Table 23? See Discussion.

      Answer:  Code the specific histology as stated by the pathologist according to the site-specific instructions in the Solid Tumor Rules. [Added font bolding for emphasis] When the histology provides a subtype/variant in addition to the HPV histology codes, code the subtype/variant as it is important to capture this histology as in the example provided. The instruction to code the subtype/variant over 8085 or 8086 applies to the following sites: oropharynx, cervix, vagina, vulva, anus, and penis. A note will be added indicating this in 2025. 

      Per 2024 Cancer PathCHART expert pathologist review, morphology codes 8085/3 and/or 8086/3 are valid and applicable to head and neck, oropharynx, cervix, vagina, vulva, fallopian tube, anus, and penis (reference: Cancer PathCHART: Product Downloads and Timelines). Other coding resources will be updated to reflect these changes in 2025.

      Coding Examples

      • A 12/20/2021 tonsillectomy (C09.9) pathology diagnosis is HPV-negative squamous cell carcinoma, comments state a p16 immunostain was negative.  No documentation in the chart of ISH or PCR testing for HPV DNA or RNA.
        • Histology = 8070/3 (squamous cell carcinoma, NOS) due to the pre-2022 diagnosis date, per Solid Tumor (ST) Head & Neck rule H1 – code the histology when only one histology is present, and Table 5.  
        • Prior to 2022, p16 results could not be used to code the HPV-specific histologies for head and neck sites; ISH or PCR testing was required, as noted on Table 5.
          • If this same case had been diagnosed in 2022 or forward, the correct histology would be 8086/3, since C09.9 is a site on ST Head & Neck Table 5, for which the HPV histology codes are permitted starting in 2022.
      • Path report from a 3/5/2024 anus (C21.0) biopsy states invasive HPV-associated squamous cell carcinoma, verrucous type, p16 positive.  
        • Histology = 8051/3 (verrucous squamous cell carcinoma), per ST Other Sites rule H15 - code the subtype/variant when there is a NOS and a single subtype/variant, Table 8, and SINQ #20240019.
        • Even though HPV-associated SqCCa and Verrucous SqCCa are both listed as subtypes of 8070/3 on Table 8, SINQ #20240019 confirms that the other subtype takes priority over an HPV-related histology for anus - although this isn’t currently stated in the notes preceding Table 8.  This SINQ implies that the HPV component is ignored, effectively resulting in only a single subtype to consider (verrucous).
      • Resection of a frontal sinus (C31.2) tumor on 11/11/2022 showed HPV-independent squamous cell carcinoma, p16 negative on pathology.  
        • Histology = 8070/3 per ST Head & Neck rule H1 – code the histology when only one histology is present, Note 1 – use Tables 1-9 to code the histology, and SINQ #20240018.
        • C31.2 is on Table 1, and 8086 for HPV-independent SqCCa is not listed on this table’s histology codes.  
        • Even though C31.2 is included in the ICD-O-3.2 updates’ Annotated Histology list as a common site for code 8086, that would not be coded per SINQ #20240018.  This SINQ clarifies that the HPV histology codes only apply to the Head & Neck sites in ST Table 5 (Oropharynx, Base of Tongue, Tonsils, Adenoids), and have not yet been implemented in the U.S. for additional sites that may be listed in ICD-O-3.2.

      KEY POINT:    Cancer registry coding guidelines for HPV-related histologies contain several restrictions based on primary site and diagnosis year.  Always check the latest version of the Solid Tumor Rules first, then SINQ and the ICD-O-3.2 updates, if needed.  If none of these guidelines fit the case being abstracted, the Solid Tumor manual instructs to submit a question to Ask-A-SEER-Registrar (https://seer.cancer.gov/registrars/contact.html) for the correct histology code.

      References

      Solid Tumor Rules, 2024 update (https://seer.cancer.gov/tools/solidtumor/2024/STM_Combined.pdf)

      • Head & Neck, Other Sites modules.  Pay attention to specific effective dates, notes and exceptions throughout chapter introduction materials and all tables.

      ICD-O-3.2 updates (see version appropriate to year of diagnosis - https://www.naaccr.org/icdo3/ )

      NAACCR Implementation Guidelines that address changes to p16/HPV histology coding

      Related questions from the SEER Inquiry System (SINQ - https://seer.cancer.gov/seer-inquiry/inquiry-search/) 

          April - Coding Visceral and Parietal Pleural Invasion (VPI) for Lung Schema

      This month for our Quality Tip, Utah Cancer Registry is featuring some reminders for coding Visceral and Parietal Pleural Invasion (NAACCR item # 3937), which we hope you find helpful.  Please submit any questions at https://redcap01.brisc.utah.edu/ccts/redcap/surveys/?s=8KC7FP8XKN. 

      Coding Visceral and Parietal Pleural Invasion (VPI)

      Visceral and Parietal Pleural Invasion is a Site Specific Data Item (SSDI) for Lung, and is defined as an invasion beyond the elastic layer or to the surface of the visceral pleura.  VPI is pertinent for peripheral lung tumors, and its presence impacts the AJCC T categories and Stage group; for example, if the tumor has VPI and is smaller than 3 cm it changes the T category from pT1 to pT2, or it changes the stage from IA to IB in patients with no nodal disease.

      Coding Examples

      • Patient found to have left lung mass, FNA biopsy proven to be moderately differentiated adenocarcinoma, predominantly acinar growth pattern. Pleural fluid was positive for malignancy consistent with adenocarcinoma. How would you code VPI?
        • ANSWER: Visceral Pleural Invasion is coded 9 - Visceral Pleural Invasion not assessed or cannot be determined.
        • RATIONALE: Per coding Note 4 in the SSDI Manual, FNA is not adequate to assess pleural layer invasion and a surgical resection was not performed.
      • Patient recently diagnosed with Squamous Cell Carcinoma of LLL lung per biopsy. He underwent a LLL lobectomy which was invasive SqCCa, tumor size was 2.6cm, margins were negative, suspicious involvement of the elastic layer is present, no LVI identified. How would you code VPI? 
        • ANSWER:  VPI is coded 4 - Invasion of visceral pleura present. 
        • RATIONALE:  The elastic layer is part of the visceral pleura, and it was noted to be suspicious for involvement on lobectomy pathology.  CAnswer Forum confirms that the SSDI workgroup agreed ambiguous terminology can be used to code involvement (see References section below).
      • Workup for hemoptysis showed a 6.5 cm right medial lung mass invading pleura and extending to mediastinum on CT scan; bilateral hilar lymph nodes were significantly enlarged, consistent with metastatic nodal disease from primary lung malignancy; large pleural effusion.  Patient was placed on chemotherapy and immunotherapy; surgery was not recommended due to advanced disease.  How should VPI be coded?
        • ANSWER:  VPI is coded 9 - Visceral Pleural Invasion not assessed or cannot be determined.
        • RATIONALE:  Although the CT scan stated the tumor invaded the pleura, imaging findings cannot be used to assess VPI; it must be evaluated on a surgical resection specimen, per SSDI Notes 2 and 3.

      KEY POINT - The SSDI for visceral pleural invasion must have a statement on surgical resection that VPI is not present to code 0; if VPI is not mentioned or only assessed by imaging or biopsy, it must be coded 9.  This is a change from Collaborative Stage v2, where if a path report was available and there was no mention of visceral pleural invasion, the registrar could assume that VPI was negative. 

      References:

       

          March - Coding Breslow Thickness from Unusual Descriptions or Measurements

      This month for our Quality Tip, UCR is featuring some hints related to melanomas, which we hope you find helpful.  Melanoma consistently ranks as one of Utah’s top five incidence cancers, so these issues will likely show up at some point in abstracting our cases.  Please submit any questions at https://redcap01.brisc.utah.edu/ccts/redcap/surveys/?s=8KC7FP8XKN. 

      Coding Breslow Thickness from unusual descriptions or measurements

      Some Site Specific Data Items (SSDIs) have instructions to code values stated to be “greater than” a certain measurement as one more than stated.  However, this is NOT the case for Breslow thickness in melanomas.

      From the SSDI Manual, site-specific instructions for Breslow Thickness:

      • Note 5: If the pathologist describes the thickness as "at least," use the appropriate A code [A0.1-A9.9]  An exact measurement takes precedence over A codes.
      • If the pathologist states "greater than" instead of "at least", code to XX.9, unless it is greater than 9.9 mm (code AX.0)

      Per CAnswer Forum, the “A” codes should NOT be used when a subsequent re-excision shows no residual tumor.  (See Coding Examples and References below).

      • Another lesser-known instruction from the SSDI manual provides guidance when pathology reports don’t specifically state “Breslow Thickness” or “Breslow depth of invasion”:  
        • “Thickness” or “depth” is acceptable, or if neither of those are stated, a measurement described as taken from the cut surface of the specimen may be coded.  In the absence of any of these labels, the third dimension in a statement of tumor size can be used to code this field.

      CODING EXAMPLES

      • Pathology report from a biopsy of the left thigh states Breslow depth:  greater than 1 mm, extending to the deep margin.  Patient did not show up for his scheduled wide excision; no additional pathology reports are available, and there’s no other indication that he had treatment elsewhere.
        • ANSWER:  Breslow Thickness SSDI is coded XX.9 
        • RATIONALE: Per SSDI note 5, Breslow Thickness should be coded as XX.9 (cannot be determined by pathologist), since it was stated as “greater than” a certain measurement.  For this SSDI, it is not permitted to code one more than the stated depth (in this case, 1.1 mm).
      • Shave biopsy was read in the dermatologist’s office, and her notes describe “a central dark brown nodule measuring 3.3 x 2 x 0.2 cm”; “superficially invasive melanoma with mitotically active melanocytes within the dermis”.  No depth or thickness is stated, and re-excision showed only focal in situ melanoma, NOS.
        • ANSWER:  Breslow Thickness SSDI is coded 2.0
        • RATIONALE:  Since there is no statement of Breslow thickness, depth, or measurement from cut surface, the SSDI manual instructs that we may code 2.0 mm in the Breslow Thickness SSDI, converted from 0.2 cm as the third measurement in the stated tumor size.  Use caution when coding from tumor size measurements, which are often stated in centimeters; the SSDI codes are in millimeters.
      • Initial punch biopsy of a small atypical upper back mole showed a Breslow thickness of “at least 0.3 mm”, extending to one lateral and the deep margin.  However, there was no residual tumor on re-excision pathology.
        • ANSWER:  Breslow Thickness SSDI is coded 0.3  
        • RATIONALE:  The negative re-excision proves that there was no greater depth than 0.3 mm.  Code A0.3 (for “at least 0.3 mm”) would be used if there were no information about a re-excision, or if the re-excision pathology showed residual melanoma with no indications of a Breslow depth.  Per SSDI Note 3, code the greatest measured thickness from any procedure performed on the lesion, whether it is described as a biopsy or an excision.

      Key Point:  Breslow Thickness for melanoma is occasionally described with non-standard terms or measurements; be sure to review the site-specific instructions in the SSDI Manual and its coding notes to ensure the correct codes are used.

      BONUS MINI-TIP/Reminder:  remember that in-transit, satellite, and/or microsatellite metastasis are coded in the EOD-Regional Nodes data item.  It’s tempting to focus only on the number of involved nodes, and neglect to include these regional mets, especially since many of the mets codes are located further down the EOD Nodes code list.  For example:

      • Use code 300 (not 000) when no lymph nodes are involved, but there are in-transit, satellite, and/or microsatellite metastasis.
      • Code 500 (not 100, 200, or 350) when only one lymph node is involved, but there are also satellite or in-transit mets.
      • Etc...

      References

      SSDI Manual, Melanoma Skin (schema 00470) site-specific instructions - https://apps.naaccr.org/ssdi/list/?_gl=1*1bpyue2*_ga*ODQ0MTA4MDQyLjE3MTA5NTcxNzE.*_ga_V7J8GWYK5P*MTcxMDk1NzE3MC4xLjAuMTcxMDk1NzE3MC42MC4wLjA. 

      CAnswer Forum post https://cancerbulletin.facs.org/forums/node/116371 

      EOD-Regional Nodes for Melanoma Skin schema (refer to latest update if registry software has been converted to NAACCR version 24) - https://staging.seer.cancer.gov/eod_public/input/3.0/melanoma_skin/eod_regional_nodes/?breadcrumbs=(~schema_list~),(~view_schema~,~melanoma_skin~) 

          February - Systemic Treatment Codes: Discussed, Refused, and Recommended

      Utah Cancer Registry’s Quality Tip this month contains a few reminders for Systemic Treatment codes to help clarify their descriptions.  Specifically, the descriptions for discussed, refused, and recommended.

      The Treatment codes for Chemotherapy, Hormone therapy and Immunotherapy are all congruent. 

      Coding Instructions

      Assign code 00 when: 

      • The patient has elected not to pursue treatment following the discussion of chemotherapy, hormone therapy or immunotherapy. Discussion does not equal a recommendation.  The patient’s decision not to pursue any of these treatments is not a refusal in this situation.

      Assign code 87 when:

      • The patient refused recommended chemotherapy, hormone therapy or immunotherapy. 

      OR

      • The patient made a blanket refusal of all recommended treatment and chemotherapy, hormone therapy or immunotherapy is a typical option for the primary site/histology. 

      Assign code 88 when:

      • The only information available is that the patient was referred to an oncologist.

      IMPORTANT NOTE: Review cases coded 88 from time to time for later confirmation of chemotherapy, hormone therapy or immunotherapy. 

      Keep in mind there are more coding instructions that were not included in these three descriptions (discussed, refused, and recommended).  Refer to the current SEER Manual for more details.

      CODING EXAMPLES:

      • A patient underwent a bone marrow biopsy and was diagnosed with a plasma cell myeloma.  They discussed standard treatment options for plasma cell myelomas with their primary care physician.  The medical record did not provide any additional information, and the patient passed away shortly after their diagnosis.
        • Chemotherapy - Code 00, there is no information in the patient’s medical record about chemotherapy, and no mention that patient was referred to an oncologist.
        • Hormone therapy - Code 00, there is no information in the patient’s medical record about hormone therapy AND there is no reason to suspect that the patient would have had hormone therapy.
        • Immunotherapy - Code 00, no mention of immunotherapy; discussion of treatment options does not equal a recommendation.
      • Patient has a long history of hyperplasia of the right breast for numerous years.  She was placed on tamoxifen.  Recently she was diagnosed with breast cancer and had a lumpectomy with sentinel lymph node biopsy performed.  Tumor size was 1 cm. Margins were free of disease and sentinel nodes were disease free (00/03).  No record of tumor marker testing or other details are available.
        • Chemotherapy - Code 00, there is no information in the patient’s medical record about chemotherapy, and there is no reason to suspect that chemo would have been recommended for this early-stage cancer.
        • Hormone therapy - Code 00, no mention of hormone therapy treating her breast cancer.  Tamoxifen was given for the patient’s breast hyperplasia before her cancer diagnosis.
        • Immunotherapy - Code 00, no mention of immunotherapy AND no reason to suspect the patient would have had immunotherapy.
      • Patient presents with fatigue, hair loss, swollen nodes and over-all not feeling well.  Work up reveals a T-cell lymphoma.  The patient stated they refuse all treatment before any recommendations had been made.
        • Chemotherapy - Code 87, patient refused all treatment before any was recommended AND chemotherapy is a customary option for T-cell lymphoma.
        • Hormone therapy - Code 87, patient refused all treatment before any was recommended AND hormone therapy is a customary option for this cancer (it is listed under Treatments in the SEER Hematopoietic Database for T-cell lymphoma, NOS - 9702/3, and is often part of multi-agent regimens).
        • Immunotherapy - Code 00, patient refused all treatment before any was recommended, BUT immunotherapy is NOT a typical option for this type of cancer (immunotherapy isn’t listed under Treatments in the Heme Database for T-cell lymphoma, NOS – 9702/3).

      Key Point:  Make sure to closely read the SEER Manual coding instructions for all systemic therapies along with the notes/examples. It’s an easy mistake to interpret “discussed” for “recommended” therapy.

      References

      SEER Manual, https://seer.cancer.gov/tools/codingmanuals/ 

      SEER Hematopoietic and Lymphoid Neoplasm Database, https://seer.cancer.gov/seertools/hemelymph/

      ----------------------------------------------------------------------------

      Questions on Quality Tips of the Month can be submitted through UCR’s inquiry system at https://redcap01.brisc.utah.edu/ccts/redcap/surveys/?s=8KC7FP8XKN. 

          January - Coding Grade for Urinary Bladder

      CODING GRADE FOR URINARY BLADDER

      Bladder is one of the primary sites that has preferred grading systems based on histology.  Per the Grade Manual:

      • Urothelial cancers: use codes L, H and 9
        • If only G1-G3 are documented, code 9
      • Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9
        • If only L or H are documented, code 9
      • The bladder grade table doesn’t include the alpha codes “A-D”, which indicates that terminology used in pathology reports can NOT be converted under the instructions for Generic Grade Categories.
      • A trans-urethral resection of bladder procedure (TURB) qualifies for a clinical grade only.  At least a partial cystectomy is required to assign pathologic or post-therapy (yP) grades.

      Bonus mini tip:  Small cell carcinomas default to the highest applicable grade in the primary site’s grading system; for bladder, this is grade 3 since small cell is not a type of urothelial carcinoma (see References section below).  The grade rules and timeframes that apply to all histologies must still be followed; for example, the highest grade cannot be coded when the only specimen showing small cell carcinoma is from a metastatic site.

      Coding Examples:

      • TURB pathology report final diagnosis:  high-grade urothelial carcinoma with extensive squamous differentiation.  Patient declined all further workup and no additional treatment was done.
        • Histology is coded 8120 (urothelial carcinoma), per the Solid Tumor manual Urinary Module:  
          • Coding Histology guidelines -- code the histology described as differentiation or features/features of ONLY when there is a specific ICD-O code for the “NOS with ____ features” or “NOS with ____ differentiation”.
          • Rule H1, note 4 -- Only code squamous cell carcinoma (8070) when there are no other histologies present (pure squamous cell carcinoma). 
        • Grade Clinical is coded “H” because 8120 is a urothelial histology, per Grade Manual table 19, bladder coding Notes.  
        • Grade Pathological is coded 9 since a cystectomy is required for pathologic grade.
      • TURB path report final diagnosis:  Poorly differentiated carcinoma.  No record of any further treatment.
        • Histology is coded 8020
          • Per rule H1, note 1:  use Table 2 to code histology.  New codes, terms, and synonyms are included in Table 2 and coding errors may occur if the table is not used. 
          • Table 2 lists poorly differentiated carcinoma as code 8020, a subtype in column 3 of the urothelial carcinoma (8120) row.
        • Grade Clinical is coded 9, since 8020 is considered a urothelial carcinoma subtype for bladder, and the path report doesn’t specify “high” or “low” grade.  Code 3-poorly differentiated should not be used for urothelial carcinomas, per Grade Clinical coding Note 4.
        • Grade Pathological is coded 9 because no cystectomy was done.
      • Bladder biopsy shows highly necrotic undifferentiated carcinoma, comment states a specific morphologic type cannot be further identified in these small fragments.  Cystoprostatectomy path report diagnosis:  Invasive high-grade carcinoma with small cell neuroendocrine carcinoma and invasive high-grade papillary urothelial carcinoma.
        • Histology is coded 8045 per rule H4 (small cell with any other carcinoma).
        • Grade Clinical is coded 9, since a specific grade was not stated clinically, and bladder is not a site where the Generic Grade categories can be used to convert the “undifferentiated” term to grade code D.
        • Grade Pathological is coded 3, because the histology is a small cell carcinoma, which is assigned the highest applicable grade and takes priority over the urothelial grade (see CAnswer Forum posts in the References section, below).

      Key Point:  Bladder has two preferred grading systems, based on histology.  Therefore, it is critical to determine the correct histologic type using the Solid Tumor guidelines, then choose the grade codes that match the histology.  If the pathology report only states a grade from a non-preferred system for the given histology, assign code 9.  

      References

      Grade Manual - https://apps.naaccr.org/ssdi/list/3.0 

      Solid Tumor Manual, Urinary module - https://seer.cancer.gov/tools/solidtumor/2024/Urinary_STM.pdf 

      CAnswer Forum posts - https://cancerbulletin.facs.org/forums/node/121365 and https://cancerbulletin.facs.org/forums/node/147838 

      Q-Tips 2023
            December - Coding Histology for Specific Gynecologic Cancers

        CODING HISTOLOGY FOR CERTAIN GYNECOLOGIC CANCERS

        High-grade serous carcinoma -- Since the 2018 ICD-O-3 updates, the terms “high-grade serous carcinoma” and “serous carcinoma, high grade” have been assigned the histology code 8461/3 for ovary, fallopian tube/some nearby structures, and primary peritoneal cancers of this type (site codes C48._, C56.9, C57.0, C57.1–C57.3).

        • Code 8441/3 for serous carcinoma NOS is incorrect for ovary and the associated sites listed above, when the diagnosis specifies high-grade serous carcinoma.  For these sites, “low-grade serous carcinoma” is coded 8460/3, and “serous carcinoma” NOS is coded 8441/3.  
        • For other primary sites, including endometrium or other GYN organs not listed above, 8441/3 is correct when the diagnosis is serous carcinoma - including high grade.  (See Coding Examples and References sections, below).
        • With the 2021 ICD-O-3 updates, several other histology terms and codes changed for ovary (C56.9), for example [not a complete list]:
          • Papillary serous adenocarcinoma – 8460/3 pre-2021; for 2021+ use 8441/3, per the ICD-O-3.2 Annotated Histology List
          • Serous surface papillary carcinoma – 8461/3 pre-2021; for 2021+ use 8441/3
          • Papillary serous cystadenocarcinoma – 8460/3 pre-2021; for 2021+ use 8441/3

         

        Coding Examples

        • Pathology from a hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) on 3/16/2023 shows bilateral ovaries C569 with serous carcinoma, high grade.
          • Histology should be coded 8461/3 per Solid Tumor Rules (STR) manual, Other Sites rule H34 (code the subtype/variant when there is a NOS and a single subtype), and Table 13 Ovary Histologies.
          • 8441/3 serous carcinoma NOS would be incorrect for this primary site and diagnosis.  For ovary, “high grade” is part of this histology term with its own code, which is listed as a specific subtype of serous carcinoma in Table 13.
            • “Serous carcinoma, high grade” is listed as an alternate term for 8461/3 “high grade serous carcinoma” on the ICD-O-3.2 Annotated Histology List.

         

        • A 9/22/2023 TAH-BSO surgery returned pathology results of high-grade serous carcinoma in the endometrium (C541).  
          • Histology should be coded 8441/3 per STR Other Sites rule H12 (code the histology when only one histologic typeis identified) and Table 16 Uterine Corpus Histologies.  In this table, serous carcinoma NOS 8441/3 has no subtypes listed; there is no separate code for “high-grade serous carcinoma”.  
            • As on other STR Tables, Table 16 is stated to list the more common histologies for uterine corpus; not every possible histology is in the table.  When a term or code is not listed in the STR tables, we are instructed to check the ICD-O-3.2 updates.  The ICD-O-3.2 Annotated Histology list doesn’t include C54.1 in the suggested site codes for code 8461/3, “high-grade serous carcinoma”.  In general, site codes other than those listed in ICD-O-3 may be assigned for a particular histology; however, SINQ #20200023 further clarifies that 8441/3 should be coded for high-grade serous carcinoma of the endometrium. 

         

        KEY POINT:    Since 2018, histology coding has become more complex with multiple updates to ICD-O-3.2 and the Solid Tumor Rules.  Do not rely on memory or software lookups to assign histology codes; always check the latest version of the Solid Tumor Rules first, then the ICD-O-3.2 update documents.  Pay close attention to any diagnosis year or primary site notations listed in these resources.  Double-check in SINQ to see if an applicable question has been posted, again being mindful of dates for the associated guidelines; then if still unsure of the correct histology code, submit a question to Ask-A-SEER Registrar.

        References

        Solid Tumor Rules, Other Sites section - https://seer.cancer.gov/tools/solidtumor/

        ICD-O-3.2 updates (version appropriate to year of diagnosis) - https://www.naaccr.org/icdo3/

        SEER Inquiry System (SINQ) # 20200023 - https://seer.cancer.gov/seer-inquiry/inquiry-detail/20200023/

            November - Coding EOD-Regional Nodes: Negative vs Unknown

        CODING EXTENT OF DISEASE—REGIONAL NODES (NAACCR item #774):  Negative versus Unknown

        When determining the code for EOD-Regional Nodes, the EOD Manual’s General Instructions make a distinction between Accessible and Inaccessible lymph nodes.

        • Accessible lymph nodes can be observed, palpated, or examined without instruments, such as the regional nodes for the breast, oral cavity, skin, or other organs with regional nodes near the body surface.  
          • Any description of these nodes, or lack thereof, should be documented in the physical exam text of the cancer registry abstract.
          • As long as there is a clinical evaluation, EOD guidelines allow coding these accessible lymph nodes as negative/not involved if they’re not mentioned as positive.  This includes general statements that the overall exam is negative or within normal limits, which should be documented in the abstract.
        • Inaccessible lymph nodes are usually within body cavities and cannot be palpated or observed by physical examination.  Some common examples would be regional nodes for bladder, colon, or lung.
          • For these inaccessible sites, if there is missing or ambiguous information about regional node involvement, EOD-Regional Nodes may be coded as negative IF the tumor is low stage or localized AND standard treatment is done.

         

        To further clarify, guidelines in the EOD Manual state:

        Code EOD Regional Nodes 000 (negative) instead of 999 (unknown) when ALL three of the following conditions are met:

        -  There is no mention of regional lymph node involvement in the physical examination, pre-treatment diagnostic testing, or surgical exploration 

        -  The patient has localized disease 

        -  The patient receives what would be the standard treatment to the primary site (treatment appropriate to the stage of disease as determined by the physician), or patient is offered usual treatment but refuses it.

        These guidelines apply only to localized cancers. Assign code 999 when there is reasonable doubt that the tumor is localized.

        Coding Examples

        • 2/5/2023 48 year old female in for evaluation of breast lump.  On exam, a small right breast nodule is palpated in the UOQ.  MRI rt breast showed a 1.5cm well defined mass in breast consistent with invasive ca, not near skin surface; normal fat plane between mass & pectoralis fascia.  2/16/2023 Core biopsy pathology report:  invasive ductal carcinoma, Nottingham 6.  Lumpectomy and radiation are recommended, but patient goes to another hospital due to insurance coverage; no records are available from the treating hospital.
        • EOD-Regional Nodes would be coded 000 - no clinical node involvement.  
        • Breast has accessible regional nodes, so even though there was no mention of lymph nodes on physical exam or imaging, EOD guidelines allow coding regional nodes as negative.  This is further supported by the evidence indicating a localized primary tumor with standard treatment recommendations.

         

        • 4/29/2023 CT chest:  enhancing 2.7 cm nodular opacity in medial RUL of lung; enlarged rt internal mammary chain and epigastric lymph nodes.  5/26/2023 PET scan: hypermetabolic spiculated nodule RUL consistent with primary pulmonary malignancy; hypermetabolic uptake in bilateral mediastinal, rt internal mammary, and left gastric adenopathy; increased activity in sacrum is suspicious for bony metastasis.  Biopsy of RUL mass shows primary lung adenocarcinoma.  No physician staging information is available, but on 6/12/2023 an outside clinic oncologist starts patient on afatinib chemotherapy as the only treatment.
          • EOD-Regional Nodes would be coded 999 – unknown if involved.
          • Lung has inaccessible lymph nodes, and even though abnormal nodes were noted on imaging, none of the terms used are considered positive for involvement by cancer registry guidelines (“enlarged”, “adenopathy”, “hypermetabolic uptake” NOS – see References section below).  Without additional physician statements, staging, or treatments that confirm nodal involvement, it cannot be coded as positive.  
          • In addition, the standard treatment for localized lung cancer is usually surgery or definitive radiation; these were not done or recommended.  Therefore, EOD guidelines do not allow the assumption that lymph nodes were negative, despite lack of acceptable involvement terms.

         

        KEY POINTS:  When lymph node information is not clearly stated, consider the stage of disease and whether regional nodes for the primary site are accessible or inaccessible; refer to EOD guidelines on when nodal involvement can and cannot be coded.  Remember that coding Unknown may be appropriate for non-localized cancers, and do not assume that every abnormal lymph node finding is due to malignancy.

        References

            October - Coding Grade Pathological in Non-Surgical Cases

        Coding Grade Pathological (NAACCR Item #3844) in Non-Surgical Cases

        It’s easy to automatically disregard pathologic data items when a patient has no resection of the primary tumor.  However, per the NAACCR Grade Manual, grade from the clinical workup from the primary tumor should also be coded in Grade Pathological, when surgical resection of the primary tumor has not been done, but there is positive confirmation of distant metastases during the clinical time frame.

        Important caveats to the above guideline:

        • The basic criteria for clinical grade must be fulfilled before it can be coded in Grade Pathological.  The clinical grade must come from a primary site specimen, during initial workup and assessment of the tumor.
        • Metastasis from a distant site must also be microscopically confirmed during the clinical timeframe, i.e., before definitive treatment or disease progression.  
          • Not all procedures coded in the surgery data items are considered treatment, for purposes of determining clinical and pathologic timeframes according to AJCC guidelines.

         

        Coding Examples

        • 5/12/2023 lung mass biopsy finds moderately differentiated adenocarcinoma.  5/27/2023 PET scan shows liver lesions compatible with metastasis; liver biopsy on 6/1/2023 confirms poorly differentiated adenocarcinoma, immunophenotype consistent with lung primary.  Patient subsequently begins chemotherapy and immunotherapy.
          • Grade Clinical (#3843) is coded 2 from the primary tumor specimen (moderately differentiated).
          • Grade Pathological (#3844) is also coded 2, since coding guidelines instruct us to use the clinical grade in this situation (positive confirmation of distant mets without primary tumor resection).  
            • Grade from a metastatic specimen is never coded in any data item.

         

        • 11/29/2022 screening mammogram reveals a 1.3 cm right breast mass suggestive of malignancy, normal axillary lymph nodes.  12/2/2022 right breast core biopsy shows invasive ductal carcinoma, Nottingham grade 3.  Physical exam and review of systems is negative; lumpectomy is recommended, but patient is lost to follow up.  She then returns on 3/25/2023 with hip pain; imaging shows a lesion in left femur and biopsy confirms metastatic breast cancer to bone.
          • Grade Clinical is coded 3 from the primary tumor biopsy.
          • Grade Pathological is coded 9, because the recommended primary tumor resection wasn’t done, and bone metastasis was not found or suspected during the initial clinical workup; this indicates disease progression.  Therefore, the clinical grade from the breast specimen cannot be coded in Grade Pathological (no confirmation of distant mets during clinical timeframe).

         

        • 7/19/2023 bladder biopsy shows high grade urothelial carcinoma.  Operative report from 8/9/2023 transurethral resection of bladder (TURB) states all visible tumor was resected; pathology again shows high grade urothelial carcinoma, invading muscularis propria.  Lung masses on 8/17/2023 chest imaging are biopsied and found to be metastatic carcinoma, compatible with urinary origin.  Patient is then started on radiation and immunotherapy.
          • Grade Clinical is coded H (high grade) from the primary tumor specimens (biopsy and TURB – both considered clinical procedures).
          • Grade Pathological is also coded H, since distant lung mets were microscopically confirmed within the clinical timeframe, before treatment (radiation and immunotherapy) was started.  
            • For bladder, at least a partial cystectomy is required for pathologic staging, so a TURB is not considered definitive treatment or part of the pathologic timeframe according to AJCC guidelines.

         

        KEY POINT:   Whenever there is a pathology specimen showing distant metastasis and no resection of the primary tumor, check to see if there is also a clinical grade that can be coded in Grade Pathological.  Coding guidelines only allow this if both the primary tumor and a distant site are biopsied within the clinical timeframe.

        References

            September - Coding Resection Surgeries for Pancreatic Cancers

        Coding resection surgeries for Pancreatic cancers

        When coding Surgery of Primary Site (NAACCR item numbers 671 and 1291) for resection of pancreatic tumors, the operative report is the primary source document that should be used to determine the most accurate code; it may be supplemented by information from the pathology report, per SEER Manual coding instructions.  Especially when deciding between codes A360 and A370, look for a description of whether the surgery was a local or partial pancreatectomy and duodenectomy with a partial gastrectomy (Whipple), or a local or partial pancreatectomy and duodenectomy without distal/partial gastrectomy (which is not a true Whipple procedure), AND document this in the abstract text.  Note that this information may be found in the narrative section of the surgeon’s techniques, and may not always match the stated name of the procedure.  

        Excerpt from Pancreas Surgery Codes in SEER/STORE Manuals:

        A350 Local or partial pancreatectomy and duodenectomy

        A360 WITHOUT distal/partial gastrectomy

        A370 WITH partial gastrectomy (Whipple)

        (Cases diagnosed prior to 2023 would use the equivalent codes 35, 36, and 37).

        Note:  A “pylorus-preserving Whipple” procedure (also known as a “mini-Whipple”) does NOT remove any portion of the stomach.  Therefore, it meets the definition for A360 (WITHOUT partial gastrectomy) in the surgery codes.

        Key Points:  

        • If the operative report only states “local or partial pancreatectomy and duodenectomy” with no further details specified, and does not describe the extent of organ removal, the correct code is A350; it cannot be assumed to be either without distal/partial gastrectomy (A360) or with partial gastrectomy (A370).  See References section below.
        • Be careful not to use surgery code A370 when the procedure is referred to as a “Whipple” but no stomach is included in the operative specimens or gross examination on the pathology report.

         

        Coding Examples

        • Operative report: 2/15/2023 Distal Pancreatectomy and duodenectomy with splenectomy; tumor in body of pancreas measures 3.4 cm; no clear details of which organs were resected.  2/15/2023 Pathology report is not available, but physician notes indicate it showed pancreatic neuroendocrine tumor, WHO grade 1, unifocal. 
          • Code Surgery as A350 - partial pancreatectomy and duodenectomy, per op report.  
          • There is no mention of partial gastrectomy, and there is not enough information to determine whether stomach was included in the resection.

         

        • Op report:  4/27/2021 Whipple procedure.  4/27/2021 Path report:  poorly differentiated 3.6 cm adenocarcinoma in pancreatic head; specimens - Whipple and gallbladder; gross examination - Whipple specimen to include head of pancreas, distal stomach, and duodenum.   
          • Code Surgery as 37 - partial pancreatectomy and duodenectomy WITH partial gastrectomy (Whipple) per op report; plus confirmation in the path gross that partial gastrectomy (distal stomach) was included.

         

        • Oncologist note:  a Whipple procedure was done on 6/7/2023 at an outside facility.  No op report is available, but a copy of the path report includes gross description stating head of pancreas and proximal duodenum are submitted; final diagnosis - Pancreaticoduodenectomy:  Well-differentiated adenocarcinoma (2.5 cm).
          • Code Surgery as A360 - Local or partial pancreatectomy and duodenectomy WITHOUT distal/partial gastrectomy.
          • Even though the oncologist referred to this as a Whipple procedure, no operative report was available to verify the details of resection, and the pathology report does not include gastrectomy.

        References

        https://seer.cancer.gov/manuals/2023/SPCSM_2023_MainDoc.pdf, pg.169

        https://seer.cancer.gov/manuals/2023/AppendixC/Surgery_Codes_Pancreas_2023.pdf

        CAnswer Forum posts by NCDB/CoC - 

        https://cancerbulletin.facs.org/forums/node/95719 

        https://cancerbulletin.facs.org/forums/node/131524#post137043

            August - Coding the SSDI "FIGO Stage"

        CODING THE SITE-SPECIFIC DATA ITEM (SSDI) “FIGO STAGE”

        FIGO Stage is one of the SSDIs for gynecologic cancers and its coding instructions were updated in the current SSDI Manual, version 3.0, with some significant changes.

        • What HAS changed?  The new coding instructions in Note 1 for the GYN sites are:  
          • There must be a statement about FIGO stage from the managing physician in order to code this data item.
            • This further clarifies the instruction from the prior version of the manual:  If FIGO stage is not documented in the medical record, code 99.
          • If "FIGO" is not included with a stated stage, then do not assume it is a FIGO stage.  
            • In the prior version, the instruction was “If a stage group is stated but it does not specify that it is a FIGO stage, assume that it is a FIGO”.  Registrars can no longer assume that “Stage __” NOS for GYN cancers refers to FIGO stage.
          • Do not code FIGO stage based on the pathology report
            • The prior version of the manual didn’t specify whether the path report could be used to code FIGO stage.  Some users may have interpreted a FIGO stage listed on a path report as fulfilling the instruction to code FIGO stage as stated in the medical record, since the path report is part of the medical record.  This is now specifically excluded.

         

        • What has NOT changed? (REMINDERS).  These instructions were carried forward from the prior SSDI Manual into the latest version, and still apply:
          • Do not code FIGO stage based only on T, N, M.  
          • FIGO stage is not the same thing as FIGO grade. Only code FIGO stage in this field, do not code FIGO grade.
          • If there is more than one FIGO stage provided from the clinical and pathological work up, code the most extensive FIGO stage.
          • The FIGO stage definitions do not include Stage 0 (Tis). Code 97 for any non-invasive neoplasm (behavior /2).

         

        NOTE:  The current SSDI Manual version 3.0 is effective for all cases diagnosed 2018 and forward, unless otherwise specified in schema-specific coding instructions.  Cases that were previously abstracted using instructions from prior versions need not be revised to incorporate any new changes.

        Coding Examples

        • 11/17/2022 endometrial biopsy – pathology report:  adenocarcinoma, endometrioid type, FIGO grade 2.  
        • 12/13/2022 hysterectomy – path report:  uterus with endometrioid adenocarcinoma, FIGO grade 2, myometrial invasion 27%; 0/2 sentinel lymph nodes; CAP synoptic section lists FIGO Stage:  IA.  
        • Physical exam and imaging give no indication of distant metastasis.  Surgeon stages as “pT1a pN0 cM0, Stage IA”.
          • the stated FIGO grade is not coded in this SSDI
          • FIGO Stage cannot be coded from the pathology report
          • TNM cannot be used as the basis for FIGO stage
          • the physician’s Stage IA was not specified as the “FIGO” stage
        • The FIGO Stage SSDI would be coded as 99 (not assessed or unknown if assessed) for this case, since:

         

        • Patient presents with abnormal Pap smear.  2/18/2023 cervix cone biopsy and LEEP – pathology report:  squamous cell carcinoma, moderately differentiated, extending horizontally 5mm, depth of invasion 1 mm; within 2 mm of margins, no lymphovascular invasion.  
        • Exam and workup were negative for any additional sites of cancer involvement.  Gynecologist states that since this is FIGO Stage IA1, only surveillance will be required going forward.
        • The FIGO Stage SSDI in this case would be coded 1A1, per the managing physician’s statement that specified the stage group as “FIGO”.

        KEY POINT:  Carefully document staging in the abstract text, and be sure to specify which staging elements were assigned by the physician versus the registrar, since ONLY the managing physician’s specific statement of “FIGO Stage” can be used for this data item.

        Reference

        SSDI Manual v3.0 - https://www.naaccr.org/wp-content/uploads/2023/02/Site-Specific-Data-Item-SSDI-Manual-v3_printed.pdf?v=1692199755 

            July - Colectomy Surgery Codes, Circumferential Resection Margin SSDI

        This month our Quality Tips involve colon surgery and the CRM.

        COLECTOMY SURGERY CODES (Surgery of Primary Site, NAACCR item #1291 for diagnosis year 2023 forward, or #1290 for 2003-2022 diagnosis years)

        Procedures to remove colon tumors are often referred to in operative reports with generic terms such as “colon resection” or “colectomy”, not otherwise specified.  These terms may be describing either segmental resection OR hemicolectomy, or less frequently, total colectomy or proctocolectomy.  To differentiate between these and their associated surgery codes, it is essential to check the op report details and document in the abstract text which portion(s) of the colon and any associated organs were removed.  Then the full code definitions must be matched to what was actually done, regardless of the procedure name stated. 

        Registry software code lookups may not contain the full code descriptions listed in the SEER and STORE Manuals; for example:

        • A300 (for 2023+ dx years) or 30 (for 2022 & prior dx years) - Partial colectomy, segmental resection
        • A400/40 - Subtotal colectomy/hemicolectomy (total right or left colon and a portion of transverse colon)
        • A500/50 - Total colectomy (removal of colon from cecum to the rectosigmoid junction; may include a portion of the rectum)
        • A600/60 - Total proctocolectomy (removal of colon from cecum to the rectosigmoid junction, including the entire rectum)

         

        In addition, the SEER Manual contains the following instruction in its Surgery of Primary Site section:

        • “Use the entire operative report as the primary source document to determine the best surgery of primary site code. The body of the operative report will designate the surgeon’s planned procedure as well as a description of the procedure that was actually performed. The pathology report may be used to complement the information appearing in the operative report, but the operative report takes precedence”.

         

        CIRCUMFERENTIAL RESECTION MARGIN site specific data item (CRM SSDI - #3823)

        The CRM is one of the most important and predictive prognostic factors in colorectal cancer, so it is critical to keep the related SSDI field clear of confounding information about other margins that may not be the CRM.

              The SSDI Coding Instructions have some very helpful clarifications for CRM, including:

        • Note 7: If the value is recorded in Centimeters, multiply by 10 to get the value in Millimeters (mm).
          • Example: CRM recorded as 0.2 cm. Multiply 0.2 x 10 and record 2.0
        • Note 11: Code XX.9 when
          • Checked “Not applicable: Radial or Mesenteric Margin” on CAP Checklist
          • Pathology report describes only distal and proximal margins, or margins, NOS
            • Only specific statements about the CRM are collected in this data item
          • CRM not mentioned in the record

        Coding Examples

        • Patient with a sigmoid colon cancer in 2023 undergoes surgery with “colon resection” listed as the procedure name on the op report.  The body of the op report states that the colon was divided along the transverse colon and the low rectum, then removed.  Pathology report showed a 3 cm tumor extending into subserosal fat, all margins negative (NOS); microscopic and gross descriptions do not mention the CRM.
          • Surgery of Primary Site is coded A400, Subtotal colectomy/hemicolectomy (total right or left colon and a portion of transverse colon) - since the op report confirmed transverse colon through rectum removal.
          • CRM is coded XX.9 per Note 11 – since only margins NOS were stated; it is unclear whether the pathologist examined the CRM specifically (see also References section below for a related CAnswer Forum post).

         

        • A 2022 ascending colon cancer is treated with a resection specified as “right colectomy” in the op report; the description indicates that the lower ileum was transected and the right colon was mobilized to the hepatic flexure, where it was stapled and passed off the surgical field.  Pathology report states Right hemicolectomy:  adenocarcinoma invading muscularis propria; closest margin:  mesenteric, distance:  2.5 cm; gross description notes that the ileum portion of the specimen measured 2 cm. 
          • Surgery of Primary Site is coded 30, Partial colectomy, segmental resection – since the op report said the resection ended at the hepatic flexure, therefore it did not extend into the transverse colon.  The “hemicolectomy” reference on the path report is ignored because the op report takes priority for determining surgery codes.  Per SEER Notes on the surgery codes in the SEER Manual, removal of a short portion of distal ileum is not coded as removal of a contiguous organ.
          • CRM is coded 25.0 – since the path report listed the mesenteric margin distance as 2.5 cm, and it must be coded in millimeters.  “Mesenteric margin” is one of several alternate names for the CRM, per SSDI Coding Note 5.

         

        KEY POINTS:  Take an extra few seconds to scan the body of the operative report for the true extent of resection, and match that to the full description of the appropriate surgery code; be sure to substantiate in the abstract text.  Carefully watch the margin terminology and units of measure in pathology reports, and only code the distance in the SSDI if it is certain that the pathologist is referring to the CRM or one of its alternate names.

        References

            June - Coding Bladder Grades and Systemic/Surgery Sequence

        Coding Bladder Grades and Systemic/Surgery Sequence

        When coding Systemic/Surgery Sequence (NAACCR item #1639), transurethral resection of the bladder (TURB) is considered a surgical procedure, but for purposes of coding Grade data items it is considered part of clinical staging.  For pathologic staging/grades, at least a partial cystectomy is required.  Patients with Stage 0a, 0is, or stage 1 bladder cancer may have intravesical BCG (Bacillus Calmette-Guerin) or chemotherapy such as Mitomycin C or Gemcitabine following a TURB, and sometimes will proceed to cystectomy. In these cases, the systemic treatment instilled during TURB is NOT considered neoadjuvant treatment, according to NCCN guidelines and clarifications in CAnswer Forum (see References section below). Therefore, pathological grade (#3844) can be assigned from cystectomy after TURB with intravesical chemo or BCG.  

        Coding example 1:  

        1/1/2022 TURB with instillation of mitomycin C: high grade urothelial carcinoma with invasion of the lamina propria

        2/1/2022 Repeat TURB: residual bladder cancer with muscle invasion

        3/1/2022 Radical cystectomy: low grade urothelial carcinoma in situ

        Code as follows, per Grade Manual version 2.1:

        • Clinical Grade – H, from initial TURB pathology report
        • Pathological Grade – H, per coding Note 8*:  Use the grade from the clinical work up when tumor behavior for the clinical diagnosis is invasive, and the tumor behavior for the pathological diagnosis [cystectomy] is in situ.
        • Post Therapy Clin Grade – Blank and Post Therapy Path Grade – Blank per Note 1:  no neoadjuvant therapy, as intravesical chemo is not considered neoadjuvant treatment.
        • Systemic Treatment /Surgery Sequence - 5, intraoperative

        (*Numbers on the Coding Notes referenced throughout this Tip may differ from the most recent version 3.0 of the Grade manual/v23 software, but content is the same).

        Patients with muscle invasive bladder cancer (clinical stage 2 or 3A) are likely to receive cisplatin-based combination chemotherapy after their TURB and before their cystectomy; this IS considered neoadjuvant treatment according to NCCN guidelines and CAnswer Forum.  Therefore, pathological grade will not be applicable in these cases, and post-therapy grade(s) (#1068/3845) will be coded instead.

        Coding example 2:

        1/1/2022 TURB: high grade urothelial with muscle invasion

        2/1/2022:  A few cycles of MVAC chemotherapy 

        3/1/2022 Radical cystectomy: low grade urothelial carcinoma in situ

        Code as follows:

        • Clinical Grade - H, from TURB path report
        • Pathological Grade - 9, per Note 9:  Neoadjuvant therapy is followed by a resection.
        • Post Therapy Clin Grade - Blank, per Note 1:  Neoadjuvant therapy completed, no microscopic exam done prior to surgery/resection of primary tumor.
        • Post Therapy Path Grade – L, per Note 3:  Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.
        • Systemic Treatment/Surgery Sequence – 7, surgery both before and after systemic therapy

         

        KEY POINT:  pre-operative systemic or radiation treatments may or may not be considered neoadjuvant therapy for purposes of coding Grade data items, although they are still coded in the treatment/sequence data items.  Be sure to check treatment guidelines of professional organizations such as NCCN or ASCO, and verify in CAnswer Forum if any information is unclear.

        References:

        2022 SEER Manual, pg. 228 - Systemic Treatment/Surgery Sequence.  https://seer.cancer.gov/archive/manuals/2022/SPCSM_2022_MainDoc.pdf

        Grade Manual, version 2.1 - General Instructions for the Time Frames for Grade; Coding Instructions and Tables - Bladder Grade 19 table.  https://www.naaccr.org/wp-content/uploads/2021/08/Grade-Manual_v-2.1-2022.pdf?v=1687374411

        NCCN guidelines for urinary bladder neoadjuvant therapy, pages BL-1, BL-5, BL-7 and BL-G.  https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf

        CAnswer Forum - https://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/urinary-tract/urinary-bladder-chapter-62/139097-neoadjuvant-therapy-for-bladder-cancer and https://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging-8th-edition/urinary-tract/urinary-bladder-chapter-62/117589-yp-staging-bladder-case

            May - SSDIs for Localized Kidney Parenchyma Schema

        Utah Cancer Registry’s Quality Tip of the month contains a few reminders for Localized Kidney tumors so we code the SSDI’s correctly. 

        Site-Specific Data Items (SSDIs) for the Kidney Parenchyma schema

        • Invasion Beyond Capsule (NAACCR item #3864)
        • Major Vein Involvement (#3886)
        • Ipsilateral Adrenal Gland Involvement (#3861)
        • Sarcomatoid Features (#3925)

         

        SSDI Manual Coding Notes for the FIRST THREE of the above items state:  If surgical resection is done and tumor is “confined to kidney” and staging is based on size, then there has been no [invasion through the capsule, involvement of major veins, or involvement of adrenal gland]. 

        This means that the SSDI information for those first 3 items does NOT have to be specifically stated to code 0, in localized tumors that have been resected. 

        IMPORTANT NOTE:  it is correct to code 9 for the first three items above when the tumor is NOT/UNKNOWN IF confined to kidney and involvement information is not stated, or there was no resection, per SSDI Coding Guidelines Code 9 when:  

        • There is no documentation in the medical record
        • Clinical diagnosis only
        • Evaluation of invasion/involvement not done or unknown if done

        In these non-localized cases, these SSDIs require a statement that the involvement in question is not present to code 0 (see Key Point and References, below).

        The fourth SSDI for Kidney, Sarcomatoid Features, always requires a statement that these are not present to code 000, regardless of stage or extent of the tumor.  If Sarcomatoid Features are not mentioned, the correct code is XX9, per Coding Note 7.

        REMINDER -- the Coding Notes instruct us NOT to use imaging findings to code any of the Kidney SSDIs.

        CODING EXAMPLES

        • Imaging shows a 3 cm mass suspicious for RCC, no metastatic disease seen.  Right Kidney resection pathology report shows tumor extending into perinephric tissue (Beyond Renal Capsule), no sarcomatoid features identified, and extension into renal sinus.  
          • Invasion Beyond Capsule is coded 4 - extension into perinephric tissue + renal sinus.
          • Ipsilateral Adrenal Gland Involvement is coded 9 - not documented in medical record, since tumor is not confined to kidney and adrenal involvement is not mentioned.
          • Major Vein Involvement is coded 9 - not documented in medical record, again cannot assume negative because tumor is not localized.
          • Sarcomatoid Features is coded 000 -  sarcomatoid features are not present, as noted in the pathology report.
        • Imaging reveals a 4.4 cm lesion most likely representing RCC, extension to the renal hilum, but no involvement of the main renal vein. Partial nephrectomy path report - Unifocal 4 cm tumor limited to the left kidney. No Rhabdoid features, tumor necrosis. 
          • Invasion Beyond Capsule is coded 0 - tumor is limited to the kidney per path report.
          • Ipsilateral Adrenal Gland Involvement is coded 0 - tumor is limited to the kidney, so can be assumed negative even though not stated.
          • Major Vein Involvement is coded 0 -  tumor is limited to the kidney per path report (imaging is not used to code kidney SSDIs).
          • Sarcomatoid Features is coded XX9 -  not documented in medical record, only Rhabdoid features noted; can NOT assume negative without a specific statement.

        Key Point: Make sure to read the notes in the SSDI Manual Version 3.0, Kidney Parenchyma (2018)+ schema. Before in Collaborative Stage v2, if a pathology report was available and there was no mention of invasion beyond capsule, major vein involvement, or adrenal gland involvement (regardless of stage), the registrar could assume that it was negative and code the CS Site Specific Factors appropriately. For the current SSDI’s, this assumption cannot be made, except as noted above for resected tumors confined to the kidney.      

                                       

        References

        SEER*RSA Extent of Disease (EOD), Kidney Parenchyma  https://staging.seer.cancer.gov/eod_public/schema/3.0/kidney_parenchyma/?breadcrumbs=(~schema_list~)

        SSDI Manual version 3, pages 367-373 https://www.naaccr.org/wp-content/uploads/2023/02/Site-Specific-Data-Item-SSDI-Manual-v3_printed.pdf

        CAnswer Forum post https://cancerbulletin.facs.org/forums/forum/site-specific-data-items-grade-2018/urinary-tract-schemas/94404-ssdi-kidney-adrenal-gland-involvement

            April - Coding the SEER Neoadjuvant Therapy Data Items

        Utah Cancer Registry’s Quality Tip for April contains hints and examples of how to code SEER’s Neoadjuvant Treatment Fields, which are required for cases diagnosed 1/1/2021 and forward.

        For these data items, Neoadjuvant Therapy is defined as:  systemic treatment (chemotherapy, endocrine/hormone therapy, target therapy, immunotherapy, or biological therapy) and/or radiation therapy before intended or performed surgical resection.   

        Please substantiate neoadjuvant codes with documentation of the treatment plan and the physician’s clinical impression of the patient’s response to neoadjuvant therapy.  

        Neoadjuvant Therapy (NAACCR item #1632)

        Criteria for the Neoadjuvant Therapy Field:

        • A physician’s treatment plan and/or statement of patient completing neoadjuvant therapy must be used
        • Must follow the recommended treatment guidelines for the type and duration of treatment for that primary site and/or histology
        • May include systemic therapy alone, radiation alone, or combinations of radiation and systemic therapy

             Note: Limited systemic therapy may be given prior to surgery but should not be coded in these fields

        Neoadjuvant Therapy Clinical Response (#1633)

        This field is to be used to document the CLINICAL RESPONSE to neoadjuvant therapy, after completion of primary & systemic therapy and before surgical resection. A managing/treating physician (oncologic surgeon, radiation oncologist or medical oncologist) statement is required to assign codes 1-5. Surgical pathology reports should not be used to code this field.

        Neoadjuvant Therapy Treatment Effect (#1634)

        This data item records the PATHOLOGIST’S DETERMINATION of neoadjuvant treatment effect on the primary tumor/site.  This data item follows the CAP definitions of treatment effect and site-specific treatment effect codes in Appendix C of the SEER Program Coding and Staging Manual. 

        Note:  There are certain primary sites where neoadjuvant therapy is not part of the standard treatment:  C42.0, C42.1, C42.3, C42.4, (Hematopoietic cases including lymphomas, leukemias, Primary Cutaneous Lymphomas, and Plasma Cell Disorders/Myeloma), C80.9.  For these cases all three fields default to code 0 – Neoadjuvant Therapy not given.

        CODING EXAMPLES

        • Patient with locally advanced breast cancer; treatment plan documented by Medical Oncologist was chemotherapy prior to surgery, which was completed as planned. Physicians did not document their impression of the patient’s response to treatment prior to the surgery. Mastectomy path synoptic report -- Treatment Effect: Present, no residual invasive carcinoma present after presurgical therapy. 
          • Abstractor MUST document the physician’s treatment plan in the abstract, and code data items as follows: 
            • Neoadjuvant Therapy: 1 – Neoadjuvant therapy completed according to treatment plan and guidelines 
            • Neoadjuvant Therapy – Clinical Response: 8 – Neoadjuvant therapy done, response not documented
            • Neoadjuvant Therapy – Treatment Effect: 1 – No residual carcinoma, Complete response
        • Patient with tonsillar cancer with extension to base of tongue. Physician indicated patient would undergo pre-operative chemotherapy and then surgical resection.  Prior to surgery, patient had an MRI which stated complete response to treatment and the surgeon decided to watch the patient for recurrence. No statement of treatment response from the managing/treating physician is documented in the patient’s chart.
          • Abstractor MUST document the physician’s treatment plan, the post-chemotherapy MRI indicating complete response to treatment, AND surgeon’s statement that they would watch the patient INCLUDING a note that they did not state a response to treatment.  Code data items as follows: 
            • Neoadjuvant Therapy: 1 – Neoadjuvant therapy completed according to treatment plan and guidelines
            • Neoadjuvant Therapy – Clinical Response: 6 – Neoadjuvant therapy done, managing/treating physician interpretation not available, treatment response inferred from imaging, biomarkers, or yc stage
            • Neoadjuvant Therapy – Treatment Effect: 7 – Neoadjuvant therapy completed and planned surgical resection not performed
          • Patient diagnosed w/breast cancer.  Due to positive COVID test, treatment was delayed. Surgeon placed patient on Tamoxifen until surgery could be completed; surgery completed 2 months later.  
            • Abstractor MUST document the treatment plan as indicated by the physician, and code data items as follows: 
              • Neoadjuvant Therapy: 0 – Neoadjuvant Therapy not given [limited systemic therapy, does not follow recommended guidelines for breast cancer neoadjuvant treatment]
              • Neoadjuvant Therapy – Clinical Response: 0 – Neoadjuvant Therapy not given
              • Neoadjuvant Therapy – Treatment Effect: 0 - Neoadjuvant therapy not given

            • Patient diagnosed with Head & Neck cancer. Managing physician recommended chemoradiation followed by resection; pt started chemoradiation, but then decided to stop all treatment.  

              • Abstractor MUST document the treatment plan, as indicated by the physician, and patient’s decision to stop treatment.  Code data items as follows:
                • Neoadjuvant Therapy: 2 - Neoadjuvant therapy started, but not completed or unknown if completed.
                • Neoadjuvant Therapy – Clinical Response: 8 – Neoadjuvant therapy done, response not documented or unknown
                • Neoadjuvant Therapy – Treatment Effect: 7 – Planned post neoadjuvant surgical resection was not completed due to patient refusal of planned surgical resection     

              References

              2021 SEER Manual pages 222-231 -- https://seer.cancer.gov/archive/manuals/2021/SPCSM_2021_MainDoc.pdf

              2021 SEER Manual Appendix C, Site-Specific Codes for Neoadjuvant Therapy Treatment Effect - https://seer.cancer.gov/archive/manuals/2021/appendixc.html?&url=/manuals/2021/appendixc.html

              SEER Inquiry System (SINQ) - https://seer.cancer.gov/seer-inquiry/inquiry-search/  SINQ inquiry # 20210038

            March - EOD Involvement Terms

        EXTENT OF DISEASE (EOD) INVOLVEMENT TERMS

        It’s always best to use the physician’s interpretation of whether certain organs, lymph nodes, or tissues are involved – either via the physician’s direct statement, physician’s staging, or their treatment plan/decisions – any of which must be well-documented in the cancer registry abstract text.  When none of those are available and the medical record documentation is unclear, the EOD 2018 General Coding Instructions (see Reference section below) contain some guidelines and a list of ambiguous involvement terms on pages 9-10, which can be used as a last resort.  

        Some examples of terms on this list are:

        Involved -- Adherent, encroaching upon, induration

        Not involved -- Abuts, encasing, reaching

        • However, per Note 1: Terminology in the individual EOD schemas takes priority over this list. Some schemas interpret certain words as involvement, such as “encasing” the carotid artery for a head and neck site, or “abutment” of blood vessels for pancreas primaries.

        When the medical record contains only descriptions that don’t appear on the EOD involvement terms list, and no physician interpretation or treatment plan is available, DO NOT assume that other abnormal findings can be used to code Extent of Disease.

        An additional caveat for EOD – Regional Lymph Nodes:

        • EOD General Instructions page 23, #5. Terms meaning lymph node involvement: For solid tumors, the terms “fixed” or “matted” and “mass in the hilum, mediastinum, retroperitoneum, and/or mesentery” (with no specific information as to tissue involved) are recorded as involvement of lymph nodes. 
          • Other terms, such as “palpable,” “enlarged,” “visible swelling,” “shotty,” or “lymphadenopathy” should be ignored for solid tumors, unless there is a statement of involvement by the clinician or the patient was treated as though regional nodes were involved. 

        IMPORTANT NOTES:

        • Several years ago, EOD guidelines contained an exception for solid tumors of the lung only, which allowed “lymphadenopathy” to be considered as involved nodes; this exception was removed in 2018.  Imaging techniques have advanced enough in recent years that involved lung nodes should now be described with more definitive terms.  
        • Hematopoietic cancers have different guidelines than solid tumors – see the SEER Hematopoietic Manual and Database.

        Coding Examples

        • 5/6/2022 PET-CT: 4.3 CM MASS IN LUL INVADING THE PERICARDIUM C/W PRIMARY MALIGNANCY; HYPERMETABOLIC ACTIVITY ALONG THE ANTERIOR LIVER.  There is no physician staging in the chart and no reference to the liver findings in dictated notes; patient declined further workup and chose hospice.
          • Hypermetabolism on a PET scan means that the cells are metabolizing more of the glucose tracer than the surrounding tissues; this can be caused by both cancerous and non-cancerous conditions, for example inflammation or trauma.  
          • There was no confirmation by the physician that the hypermetabolic liver activity on the PET scan was related to the patient’s lung primary, and there was no treatment from which to infer possible involvement.  Since “hypermetabolic” is not on the EOD list of involvement terms, this information would be disregarded and NOT coded in EOD – Mets.
        • 6/29/2022 CLINIC H&P:  NECK MASS WITH ENLARGED LEVEL 2 ADENOPATHY OF APPROXIMATELY 4 CM; EXOPHYTIC LEFT TONSIL MASS. FNA of the tonsil mass was taken in office and cytology showed squamous cell carcinoma, but patient could not be contacted after several attempts and never returned; no further physician notes or staging in chart.
          • Adenopathy of lymph nodes simply means that they are abnormally enlarged, which can be caused by non-cancerous conditions such as illness or an immune system disorder.  For solid tumors, additional physician confirmation is needed to determine whether lymphadenopathy is due to cancer, based on the patient’s entire clinical picture.
          • In this case, since there was no physician interpretation of the adenopathy noted on physical exam, and no treatment to indicate whether nodes were felt to be involved, this information must be ignored when coding EOD – Regional Nodes.
        • 10/17/2022 PET-CT: MASS IN RECTUM C/W KNOWN MALIGNANCY; HYPERMETABOLIC LIVER LESIONS POTENTIALLY REFLECTING METS. 10/17/22 MRI ABD: 3 OVOID LESIONS C/W SMALL HEPATIC HEMANGIOMAS, NO CONVINCING EVIDENCE FOR METS DZ (PER RAD ONC NOTE 12/3/2022: ON OVERVIEW INTERPRETED C/W LIVER METS).  11/14/22 MRI RECTAL (STAGING): RECTAL CA PRESENT STAGE T3b, N1; TUMOR INVADES PERIRECTAL FAT; LOBULATED ADJACENT ADENOPATHY (17MM) N1.
          • In this well-documented case, the physicians’ interpretations and staging clarify the otherwise non-definitive terms “hypermetabolic” and “adenopathy”, so that coding positive tumor involvement in EOD – Regional Nodes and EOD – Mets is substantiated.

         

        KEY POINT:   Rather than basing EOD codes on variable terms from a few isolated reports, clearly document the physician’s overall interpretation (or inferences from their staging and treatment plan), to substantiate involvement of tissues or organs.  Only when this information is not available should the EOD ambiguous involvement terms list be used, and terms not on this list should be disregarded without further confirmation.

        Reference

        SEER Extent of Disease 2018 General Coding Instructions - https://seer.cancer.gov/tools/staging/eod/2018_Extent_of_Disease_General_Instructions.pdf

            February - Acceptable Assumptions for HBOC Data Items, Reportability of "-RADS" Imaging Categories Update

        I.  ACCEPTABLE ASSUMPTIONS FOR HBOC DATA ITEMS

        Last month, we received a question on this Coding Example that was included in our Quality Tip for Hereditary Breast and Ovarian Cancer (HBOC) data items:

        • “12/20/2021 GENETIC TESTING NEG.”  This text provides no substantiation for any of the HBOC data items, because it doesn’t specify whether any BRCA genes were tested, or if non-BRCA genes were tested; also, genetic counseling referral is not addressed.  
          • If this is the only information in the medical record, document this clearly, adding for example “no specific genes stated, no further details in chart”, and code all HBOC items as 9 - unknown or no information.

         

        Clarification

        UCR’s official Guidelines for HBOC data items (see References below) include the following example:

        • Genetic counselor note states 47 genes tested all negative. No other information in the medical record. Code Germline BRCA Testing to 1 (BRCA testing was done) and document that this was an assumption. If the test name is included, include it in the documentation.

        The same example is included under the HBOC BRCA 1 and 2 Results data items, with the instruction to code these items as 0 (negative/normal).

         

        In contrast to the Coding Example from our January Quality Tip where the only information documented was “genetic testing negative” with no further details, the above example from the Guidelines contains important clues that the testing done was indeed for germline inherited breast or ovarian cancer genes.  

        • The information came from a genetic counselor’s note and mentions testing of many genes, which in combination indicates that this was the type of germline panel testing typically done for hereditary mutations.  
        • This differs from somatic gene tests, which may be the type of “genetic testing” sometimes referred to in oncologist’s or other physician notes.  Somatic tests are increasingly being ordered on tumor tissue, to look for specific mutations within the tumor cells themselves.  These can help predict tumor response to certain treatments, for example, the PIK3CA gene for alpelisib therapy.  Somatic (tumor tissue) genetic testing is NOT to be coded in any of UCR’s Germline HBOC data items.  Germline tests are done on normal body tissues such as blood or saliva.  
        • If the only information in the patient’s record is “genetic testing negative” with no further clues, there’s no way to tell if the testing was somatic or germline testing, or even if the patient may have been tested for an unrelated genetic syndrome.  In this case, the HBOC data items should be coded to 9 (unknown), as instructed in January’s Quality Tip.  Assuming that “negative NOS” results would have included BRCA or other HBOC-related genes could skew the data, by classifying these patients in the same group as those who had KNOWN negative BRCA/HBOC results. 
        • Evidence of details that support an assumption of HBOC germline panel testing must be documented in the abstract text.

         

        II:  REPORTABILITY OF “RADS” IMAGING CATEGORIES

        Update

        In past Quality Tips, UCR has cited an entry from the SEER Inquiry System (SINQ) number 20210075 that outlined reportability based on American College of Radiology’s “-RADS” categories (Reporting And Data Systems).  Some of these are also documented in the SEER Manual, Appendix E.  SEER has recently updated this SINQ to include some helpful effective dates; there were no changes to the actual reportability of each category.

        The following cancer cases are reportable unless there is information to the contrary.

        • Liver cases with an LI-RADS category LR-4 (reportable since 2021) or LR-5 (reportable since 2016)
        • Prostate cases with a PI-RADS category 4 or 5 (reportable since 2017)

        The following are not reportable without additional information.

        • Breast cases designated BI-RADS 4, 4A, 4B, 4C or BI-RADS 5
        • Lung cases designated Lung-RADS 4A," 4B, or 4X
        • Liver cases based only on an LI-RADS category of LR-3
        • Colon cases with only C-RADS information (C-RADS category C4 is not reportable by itself)
        • Head and Neck cases with only NI-RADS information (NI-RADS category 3 is not reportable by itself)
        • Ovarian or fallopian tube cases with only O-RADS information (none of the O-RADS categories are reportable without additional information)
        • Thyroid cases with only TI-RADS information (none of the TI-RADS categories are reportable without additional information)

         

        References

        Guidelines for Statewide Collection of Genetic Counseling and Testing of Hereditary Breast and Ovarian Cancer Syndrome (HBOC) 2022 - 

        https://uofuhealth.utah.edu/documents/statewide-collection-of-genetic-counseling-and-testing-of-hereditary-breast-and-ovarian 

        SEER Inquiry System (SINQ) - https://seer.cancer.gov/seer-inquiry/ 

        2022 SEER Manual, Appendix E - https://seer.cancer.gov/archive/manuals/2022/SPCSM_2022_Appendix_E.pdf 

            January - Best Practices for Documenting HBOC Data Items

        BEST PRACTICES FOR DOCUMENTING HBOC DATA ITEMS

        Utah Cancer Registry requires the following six state-specific data items from all reporting facilities, on eligible breast and ovarian cases diagnosed January 1, 2019 and forward (see References section below for full documentation and guidelines).  Our state edits set should alert abstractors if a case is HBOC-eligible or not. 

        HBOC – GENETIC COUNSELING REFERRAL 

        HBOC -- GERMLINE BRCA TESTING 

        HBOC – GERMLINE BRCA1 RESULTS

        HBOC – GERMLINE BRCA2 RESULTS

        HBOC – GERMLINE BRCA NOS RESULTS 

        HBOC – GERMLINE OTHER GENE RESULTS, NOT BRCA

         

        Quick Tips for efficient and adequate text documentation to substantiate HBOC codes

        • The “Text--DX Proc--Lab Tests” (NAACCR item #2550) section of the abstract is the preferred place to document HBOC items.
        • It isn’t necessary to list every individual gene included in these tests, but DO document all BRCA and VUS (Variants of Unknown Significance) results; also indicate whether non-BRCA genes as a group were tested.
        • Note any “recommendations only”, or unknown information, when the medical record is incomplete or missing results.
        • Include documentation of genetic counseling referrals, in addition to the actual test results.  The fact that the patient had genetic testing does not automatically mean that they underwent formal genetic counseling; it is possible for providers to order these tests without referring the patient for counseling.

         

        Coding Examples -actual text from abstracts received at UCR (facility & provider names changed for privacy):

        • POOR documentation examples
          • “12/20/2021 GENETIC TESTING NEG.”  This text provides no substantiation for any of the HBOC data items, because it doesn’t specify whether any BRCA genes were tested, or if non-BRCA genes were tested; also, genetic counseling referral is not addressed.  
            • If this is the only information in the medical record, document this clearly, adding for example “no specific genes stated, no further details in chart”, and code all HBOC items as 9 - unknown or no information.

          • “COVID-19 VIRAL NEG 2/9/21.  2/9/21 CA-125: 49”.  This was the entire Lab Tests text for an ovarian cancer case where all HBOC data items were coded as 9.  Although it could be assumed that no information was available, there’s technically no substantiation for code 9 and it’s not clear whether the abstractor even looked for these items.  It’s preferable to make a brief explanatory note in the text, for example “no mention of genetic testing or counseling”.

             

        • BETTER documentation examples
          • “7/1/2022 Invitae Genetic Test: Negative including BRCA1 & BRCA2.”  This supports codes for the data items BRCA Testing, BRCA1, BRCA2, and BRCA NOS.  Because it was described as “including BRCA”, it could be inferred that Non-BRCA testing was also done and negative, although it would be better to state this more clearly to differentiate from a ‘BRCA 1 & 2-only’ test.  There’s no documentation for the Genetic Counseling Referral data item.  

          • “5/17/2022 (AMBRY GENETICS) BRCA1/2: NEG.”  Provides substantiation for BRCA Testing, BRCA1, BRCA2, and BRCA NOS data items, but doesn’t contain clear information for the Non-BRCA item (was this done and negative, or not/unknown if done?)  Again, the Genetic Counseling Referral item wasn’t addressed.

             

        • BEST documentation examples
          • “1/8/20 (Facilty XYZ):  GENETIC COUNSELING; BRCA 1 & 2 NEG, 12 OTHER GENE VARIANTS NEG.”  
          • “Unk if pt referred to genetic counselling; 3/4/2019 Myriad MyRisk Multigene (including BRCA1/2): VUS id'd in POLE only; remainder negative.”
          • “Per Dr. X’s 9/17/2022 progress note @ ABC Oncology Clinic:  BRCA (NOS) = NEG – no other info on testing/counseling in EMR”.

        All three of these examples substantiate every HBOC data item and leave no doubt as to the correct codes, even when complete information was not available.

         

        KEY POINT:   As noted in the NAACCR Data Dictionary description of the Text--DX Proc--Lab Tests data item, text documentation is heavily utilized for quality control and special studies, is needed to justify coded values, and facilitates consolidation of information from multiple reporting sources at the central registry.  This is especially true for UCR’s HBOC data items, since there is extensive variation in what types of tests or counseling may be ordered by providers and in results from different labs. 

        References

        Guidelines for Statewide Collection of Genetic Counseling and Testing of Hereditary Breast and Ovarian Cancer Syndrome (HBOC) 2022 - 

        https://uofuhealth.utah.edu/documents/statewide-collection-of-genetic-counseling-and-testing-of-hereditary-breast-and-ovarian 

        NAACCR Data Dictionary – http://datadictionary.naaccr.org/default.aspx?c=10&Version=22#2550 

        Q-Tips 2022
              December - Coding Sentinel Lymph Node Procedures

          CODING SENTINEL LYMPH NODE PROCEDURES

          Below is a summary of a few critical points covered in both the SEER and STORE Manuals, under Scope of Regional Lymph Node Surgery (NAACCR Data Item #1292):

          • Use the entire operative report as the primary source document to determine whether the operative procedure was a Sentinel Lymph Node Biopsy (SLNBx), a more extensive regional lymph node dissection (RLND), or a combination of both.
          • The pathology report may be used to complement this information, but the operative report takes precedence.
          • Additional NON-sentinel nodes that are removed during a sentinel lymph node biopsy are coded as a SLNBx (code 2 – NOT 6), whether the additional nodes were discovered by the pathologist or selectively harvested by the surgeon.   
            • If the operative report confirms that an additional regional lymph node dissection followed the SLNBx, code as 6 (or 7, if the regional dissection was done as a separate surgical event).
          • If SLNBx is attempted and the patient fails to map (i.e., no sentinel lymph nodes are identified by dye and/or radio label injection), these cases are still coded as sentinel lymph node procedures -- codes 2, 6, or 7 depending on whether and when an additional regional lymph node dissection was done.

          Coding Examples:

          • 11/06/2022 RADICAL RESECTION OF SCALP MELANOMA WITH SENTINEL LYMPH NODE RESECTION:  Op report describes injecting dye and removing nodes identified as sentinel; two additional nodes did not take up the dye but looked abnormally enlarged and were also removed.  
          • Pathology states 1 of 4 sentinel lymph nodes positive for metastatic melanoma; 2 additional non-sentinel nodes negative for malignancy; tumor summary lists Total number of lymph nodes examined:  6, Number of sentinel nodes examined:  4.
            • Scope of Regional Lymph Node Surgery is coded as 2 - SLNBx only, because that is the procedure described in the op report.  Per the coding manual guidelines above, the additional non-sentinel nodes removed do not impact the code, since they weren’t part of an additional more extensive dissection procedure to regional lymph nodes.
          • 7/20/2022 LEFT BREAST LUMPECTOMY WITH SENTINEL LYMPH NODE BIOPSY:  Op report states sentinel nodes were initially biopsied and frozen section path results came back positive for metastasis, so a further axillary node dissection was undertaken before closing all incisions.  
          • Final pathology shows Lymph node, left sentinel #1 (excision):  one lymph node without metastatic carcinoma (0/1); Lymph node, left sentinel #2 (excision):  one lymph node with metastatic carcinoma (1/1); Lymph nodes, left axillary (excision):  three of five lymph nodes with metastatic carcinoma (3/5).  
            • Scope of Regional Lymph Node Surgery is coded as 6 – SLNBx with an additional resection procedure to regional lymph nodes.  Even though it wasn’t stated in the name of the procedure on the op report, and all path specimens were labeled as “excisions” NOS, the surgeon’s findings and description indicate that an intentional ALND was done in addition to the sentinel node biopsy.
          • 6/29/2022 LAPAROSCOPIC HYSTERECTOMY WITH PELVIC SENTINEL LYMPH NODE MAPPING, FOR ENDOMETRIAL CANCER:  Op report states a sentinel lymph node biopsy was attempted, but no nodes took up the tracer material; nodes looked grossly normal so the decision was made not to harvest any.  
          • Pathology states no lymph nodes submitted or found.
            • Scope of Regional Lymph Node Surgery is coded as 2, since a sentinel lymph node biopsy was intended and attempted, even though no SLNs could be identified and no additional nodes were removed.

          KEY POINT:  Compare coding manual guidelines to the full description of the intended lymph node procedure and removal in the operative report; don’t rely only on the op report title or pathology results to determine the Scope of Regional Lymph Node Surgery code.

          References

          2022 STORE Manual, pages 237-243; https://www.facs.org/media/weqje4pk/store-2022-12102021-final.pdf 

          2022 SEER Manual, pages 174-177; https://seer.cancer.gov/archive/manuals/2022/SPCSM_2022_MainDoc.pdf 

              November - Pericolic/Perirectal Tissue Invasion: Summary Stage and EOD-Primary Tumor

          PERICOLIC/PERIRECTAL TISSUE INVASION:  SUMMARY STAGE AND EOD-PRIMARY TUMOR

          In the AJCC TNM staging system, invasion into pericolorectal tissues is assigned T3; however, this category is further subdivided in the SEER Summary Stage and Extent of Disease (EOD) systems.  Differences in peritonealization of some sub-sites can determine whether a case is Localized versus Regional in Summary Stage and EOD.  Researchers performing population-based studies very often request Summary Stage from UCR, so it is crucial to code this correctly.

          Per Coding Notes in the Colon and Rectum schema of SEER’s Registrar Staging Assistant (RSA) software:

          EOD-Primary Tumor Note 5: Invasion into "pericolonic/pericolorectal tissue" can be either codes 300 or 400, depending on the primary site. Some sites are entirely peritonealized; some sites are only partially peritonealized or have no peritoneum. Code 300 may not be used for sites that are entirely peritonealized (cecum, transverse colon, sigmoid colon, rectosigmoid colon, upper third of rectum).

          • Code 300 
            • Invasion through muscularis propria or muscularis, NOS
            • Non-peritonealized pericolic/perirectal tissues invaded [Ascending Colon/Descending Colon/Hepatic Flexure/Splenic Flexure/Upper two thirds of rectum: Posterior surface; Lower third of rectum]
            • Subserosal tissue/(sub)serosal fat invaded
          • Code 400 
            • Mesentery
            • Peritonealized pericolic/perirectal tissues invaded [Ascending Colon/Descending Colon/Hepatic Flexure/Splenic Flexure/Upper third of rectum: anterior and lateral surfaces; Cecum; Sigmoid Colon; Transverse Colon; Rectosigmoid; Rectum: middle third anterior surface]
            • Pericolic/Perirectal fat
          • If the pathologist does not further describe the “pericolic/perirectal tissues” as either “non-peritonealized pericolic/perirectal tissues” vs “peritonealized pericolic/perirectal tissues” and the gross description does not describe the tumor relation to the serosa/peritoneal surface, and it cannot be determined whether the tumor arises in a peritonealized portion of the colon, code 300.

          Summary Stage Note 6 is very similar to the above, with Localized/code 1 being prohibited for sub-sites that are entirely peritonealized.  

          KEY POINT:  When abstracting a colorectal case described as invading pericolic/perirectal tissues or T3, check the EOD and Summary Stage coding notes in SEER*RSA to determine the correct codes for that tumor’s specific sub-site.  

          Coding Examples

          • Right hemicolectomy pathology report, final diagnosis:  WELL-DIFFERENTIATED ADENOCARCINOMA; TUMOR MEASURES 2.3 CM, ARISES IN THE CECUM AND INVADES THROUGH THE MUSCULARIS PROPRIA; SEVEN LYMPH NODES WITHOUT MALIGNANCY.  Microscopic description:   tumor extends into the pericolonic connective tissue.  CAP synoptic summary:  pT3 pN0.  No evidence of distant metastasis on scans.
            • The correct code for EOD-Primary Tumor is 400 per Note 5, and code 2 for Summary Stage per Note 6.
            • Cecum is a site that is entirely peritonealized, therefore EOD code 300 and Summary Stage code 1 cannot be used for T3 invasion of pericolic tissues in this case.
          • Rectal adenocarcinoma found on colonoscopy with biopsy.  MRI of rectum shows CIRCUMFERENTIAL INFERIOR RECTAL CANCER, T3 N0; EUS of rectum shows TUMOR AT VERY DISTAL RECTUM, INVADES THROUGH MUSCULARIS PROPRIA INTO SURROUNDING TISSUES, T3 N0.  Neoadjuvant chemoradiation is given; due to complete response and patient’s performance status, the previously planned resection is cancelled.
            • The correct codes are EOD-Primary Tumor 300 and Summary Stage 1, since this T3 tumor is in the lower rectum, which is a non-peritonealized site per the coding notes.

          References

          SEER Registrar Staging Assistant (RSA), EOD schemas  https://staging.seer.cancer.gov/eod_public/list/2.1/ - see Colon and Rectum schema.

          AJCC Cancer Staging Manual, 8th Edition  https://link.springer.com/book/9783319406176 

              October - Coding Histology for Pancreas Tumors

          CODING HISTOLOGY FOR PANCREAS TUMORS

          Over the past several years, the terminology and reportability for tumors of the pancreas has changed considerably; a few examples are listed below.  Until the Other Sites module in the SEER Solid Tumor manual is updated, its rules for coding pancreas histology should still be followed, but may not include some of the newer terms.  In these cases, consult the ICD-O 3.2 update materials (see References below) to help determine the correct histology code.  Careful attention must be paid to the exact wording used, as just a small variation can change the code.

          Coding Examples from ICD-O 3.2 v22 Annotated Histology list*:

          *some codes vary by diagnosis year, always check the original source documents

          8240/3   Neuroendocrine tumor [NOS], grade 1

          8249/3   Neuroendocrine tumor [NOS], grade 2

          8249/3   Neuroendocrine tumor [NOS], grade 3

          8246/3   Neuroendocrine neoplasm, poorly differentiated

           

          8246/3   Neuroendocrine carcinoma, NOS

          8240/3   Neuroendocrine carcinoma, low grade

          8249/3   Neuroendocrine carcinoma, moderately differentiated

           

          8150/3   Pancreatic neuroendocrine tumor, nonfunctioning

          8150/3   Islet cell adenoma [or adenomatosis]

          8150/3   Islet cell tumor, NOS

          8150/0   Islet cell tumor, benign

           

          8453/0   Intraductal papillary-mucinous adenoma

          8453/0   Intraductal papillary-mucinous tumor with moderate dysplasia

          8453/2   Intraductal papillary mucinous neoplasm with high-grade dysplasia

          8453/3   Intraductal papillary mucinous carcinoma, invasive

          8453/3   Intraductal papillary-mucinous neoplasm with an associated invasive carcinoma

           

          Key Point:  For pancreas tumors, histologic terms and reportability may differ considerably from tumors of most other organs.  Carefully review the exact wording of the pathology diagnosis using the latest ICD-O 3.2 resources (see below).  In particular, the Annotated Histology list contains helpful notes about which terms and codes are reportable for different diagnosis years.  In addition, refer to the SEER Inquiry System (SINQ), and if still unsure of the correct histology code or reportability, submit a question to Ask-A-SEER-Registrar.

          References

          ICD-O 3.2 update materials (pre-2023) - https://www.naaccr.org/icdo3/#1582820761130-74100b9f-e677 

          SEER Inquiry System (SINQ) - https://seer.cancer.gov/seer-inquiry/inquiry-search/ , for example inquiry # 20190079.

          Ask a SEER Registrar - https://seer.cancer.gov/registrars/contact.html

              September - Coding Resection Surgeries for Brain Tumors

          Coding resection surgeries for Brain Tumors

          When coding Surgery of Primary Site (NAACCR item #1290), including resection of brain tumors, the operative report is the source document that should be used to determine the most accurate code.  In particular, when deciding between codes 20 and 30, look for a description in the op report of whether the brain tumor was felt to be completely removed (gross total resection) or if some tumor was left behind (subtotal resection), AND document this in the abstract text.  Note that this information may be found in the narrative section of the surgeon’s techniques, if it’s not in the name of the procedure.  

          Excerpt from brain Surgery Codes in SEER/STORE Manuals:

          20 Local excision of tumor, lesion or mass; excisional biopsy
               21 Subtotal resection of tumor, lesion or mass in brain
               22 Resection of tumor of spinal cord or nerve
          30 Radical, total, gross resection of tumor, lesion or mass in brain

          Key Points:  

          • If the operative report only states “resection” not otherwise specified, and does not describe the extent of tumor removal, the correct code is 20; it cannot be assumed to be either a total resection (30) or a subtotal resection (21).  See References section below.
          • Post-operative imaging describing the status of residual tumor should NOT be considered when determining the surgery code.  Surgery codes capture the surgeon’s intent and findings at the time of the operation. 
            • Note:  Intra-operative imaging is performed specifically to assess the extent of tumor removal during the procedure.  This would be included in the surgeon’s op report dictation and therefore it can be used to determine surgery code; add this to the abstract text for substantiation.

          Coding Examples

          • Operative report documentation:  3/4/22 - RIGHT TEMPORAL CRANIOTOMY FOR SUBTOTAL RESECTION OF BRAIN MASS.  Pathology report:  BRAIN MASS, RIGHT, RESECTION: GLIOBLASTOMA, WHO Grade IV.  3/5/2022 MRI:  Expected changes status post resection of right temporal lobe mass with no associated enhancing nodularity in the surgical bed. 
            • Code Surgery as 21 - subtotal resection, per op report.  
            • Disregard the path and imaging reports which may seem to suggest total resection.
          • Op report documentation:  5/25/2022 – RESECTION OF POSTERIOR FOSSA MASS.  Path report:  BRAIN, POSTERIOR FOSSA TUMOR, RESECTION:  ANAPLASTIC EPENDYMOMA.  6/9/2022 MRI:  Interval resection of the tumor along the dorsal medulla; no evidence of residual tumor on this examination.
            • Code Surgery as 20 - local excision of brain mass, since the extent of resection (total or subtotal) from the op report was not documented.
            • Disregard the information from the path and imaging reports which may seem to suggest total resection.  
          • Op report documentation:  10/31/2021 RT OCCIPITAL CRANIOTOMY FOR TUMOR RESECTION: ALL GROSSLY ABNORMAL TISSUE WAS RESECTED PER DR SMITH.  Path report:  RIGHT OCCIPITAL BRAIN BIOPSY:  DIFFUSE ASTROCYTOMA.  11/20/2021 MRI:  Linear focus of parenchymal enhancement along the resection bed; this is favored to represent residual tumor.
            • Code Surgery as 30 – gross total resection, per op report documentation.  Even though the procedure name did not state total resection, the surgeon noted in the body of the report that all visible tumor was removed.
            • Disregard the path and imaging reports which may seem to suggest biopsy or subtotal resection.

          References

          2022 SEER Manual – Surgery of Primary Site section:  Use the entire operative report as the primary source document; the pathology report may be used to complement the information appearing in the operative report, but the operative report takes precedence.

          CAnswer Forum post by NCDB/CoC - https://cancerbulletin.facs.org/forums/forum/fords-national-cancer-data-base/store/first-course-of-treatment-aa/surgery-aa/123289-brain-surgery-code-based-on-post-op-mri

              August - Staging of Intramucosal Tumors in Gastrointestinal Sites

          This month we highlight one of the few differences between AJCC TNM staging and Extent of Disease/Summary Stage.

          Staging of intramucosal tumors in Gastrointestinal Sites

          For all GI schemas in the Extent of Disease and Summary Stage systems, tumors described as intramucosal, or confined to the muscularis mucosa or lamina propria, are coded as invasive /3 for ICD-O-3 behavior (NAACCR item #523) and as 1 - Localized for Summary Stage (#764).  The exact codes vary for Extent of Disease-Primary Tumor (#772), but these types of tumors are NOT coded as 000 - in situ/non-invasive.

          In contrast, AJCC guidelines differ ONLY for tumors staged with the Appendix and Colon-Rectum chapters 19 and 20, wherein tumors stated as intramucosal or limited to the lamina propria are assigned the Tis designation (NAACCR items #1001 and 1011) for the in situ category.  Note that all other applicable GI chapters in the AJCC manual classify intramucosal, muscularis mucosae, or lamina propria tumors with the T1 category, which aligns with Summary Stage and EOD.  

          As a reminder, UCR only requires AJCC TNM data items for facilities with cancer programs accredited by the Commission on Cancer (CoC), although other facilities may choose to submit them.  EOD and Summary Stage are required for all facilities.

          Coding Examples

          • 10/18/2021 RIGHT HEMICOLECTOMY, pathology final diagnosis:  SESSILE TUBULOVILLOUS ADENOMA WITH WIDESPREAD INTRAMUCOSAL CARCINOMA; NO INVASION IDENTIFIED; ALL MARGINS NEGATIVE.  Microscopic description:  widespread intramucosal carcinoma showing a proliferation of small tubular and cribriform glands which are contained within lamina propria; there is no submucosal or muscular propria invasion.
            • Code histology/behavior as 8010/3, Summary Stage as 1, EOD-Primary Tumor as 050, and AJCC Pathological T as pTis.
            • Pathologists may use the terms “no invasion” or “non-invasive” differently than cancer registry guidelines do; read the microscopic description or consult the pathologist to determine which layers of tissue are being referenced.
          • 1/23/2022 scope found an 8 mm nodule in the JEJUNUM, BIOPSIED; pathology final diagnosis:  INTRAMUCOSAL ADENOCARCINOMA, WELL DIFFERENTIATED.  CT abdomen was negative.  
            • Code histology/behavior as 8140/3, Summary Stage as 1, EOD-Primary Tumor as 100, and AJCC Clinical T as cT1.

          Key Point:  ONLY colorectal (C18._ to C20.9) sites use the Tis classification for intramucosal GI tumors in the AJCC system, and even these are coded as invasive cancers for Behavior, Extent of Disease, and Summary Stage items.

          References

          SEER*RSA (Registrar Staging Assistant) https://staging.seer.cancer.gov/eod_public/list/2.1/ 

          • Schemas for gastrointestinal sites; see especially Colon and Rectum schema, EOD-PT Note 2 and Summary Stage Note 4.

          AJCC Cancer Staging Manual, 8th edition – GI chapters

              July - Hematopoietic/Lymphoid Cancers: Mets at Dx-Other, Transplant Dates, and High-Risk Cytogenetics

          This month we have a few mini-tip reminders that mainly relate to Hematopoietic and Lymphoid cancers. 

          Mets at Diagnosis--Other for lymphomas with bone marrow involvement

          • In addition to capturing bone marrow involvement in the EOD-Primary Tumor field (NAACCR item #772), it should also be coded in the Mets at Diagnosis—Other field (#1117) for lymphomas whose primary site is not C421.  
            • There is a standard edit (tag #N6309) for 2021 and forward cases, if Mets Other is coded 1 and EOD-PT is not 700 or 800; but not for the reverse combination (EOD-PT 700/800 with Mets Other 0).
          • Coding Example:  biopsies of a left inguinal lymph nodes and bone marrow both show involvement with follicular lymphoma; there is no other evidence of disease on staging scans.  Code site as C77.4, EOD-Primary Tumor as 800, and Mets at Dx—Other as 1.

          Bone marrow transplant dates

          • Unlike most treatments, there is no standard data item in which to code the date of bone marrow transplants.  This procedure should be coded in the Transplant/Endocrine Procedures field (#3250) and date should be documented in the abstract text.  
            • Do NOT enter codes referring to transplants in the Other Treatment (#1420) or Date Other Treatment (#1250) data items, simply to have a place to code the date; these fields do not apply to transplants.
            • Reminder:  if stated as a stem cell transplant, code 20 takes priority over 10-12 (NOS, autologous/allogeneic) – see References below.
          • Coding Example:  on 1/19/2021, patient receives an allogeneic stem cell transplant for B-lymphoblastic leukemia.  Code Transplant/Endocrine Procedures as 20.  The date of the transplant may be documented in the Remarks Text field (#2680), which the NAACCR Data Dictionary states is to document information for which the abstract provides no other place.  It is acceptable but less preferable to document transplants in the Other Therapy Text field (#2670), since transplants are NOT coded in the Other Therapy data items.

          High Risk Cytogenetics site-specific data item (SSDI)

          • High Risk Cytogenetics (#3857) is a SSDI for multiple myeloma, defined as one or more of t(4;14), t(14;16), or del 17p identified from FISH test results.  These three genetic alterations are the only ones that apply for this SSDI.
            • However, do not assume these genetics are not present if they aren’t mentioned; code 9 (high risk cytogenetics not assessed or unknown if assessed).
            • A physician’s statement can be used to code this data item, and it takes precedence over the actual test results if they differ.
          • Coding Example:  myeloma patient with bone marrow FISH results showing a 9q34 gain and 11q13 loss; no evaluation of other alterations noted.  Oncologist states treatment will begin with the KRD regimen.  Code the High Risk Cytogenetics SSDI as 9 since neither the FISH report nor the physician notes mention high risk genetics or the three specific alterations applicable to this data item.

          References

          2022 SEER Manual (https://seer.cancer.gov/manuals/2022/SPCSM_2022_MainDoc.pdf)

          • Mets at Diagnosis—Other, instruction 2b-ii
          • Hematologic Transplant And Endocrine Procedures, instruction #5

          SEER Inquiry System, question IDs 20180012 and 20031069 regarding transplants.

          NAACCR Data Dictionary version 22 (http://datadictionary.naaccr.org/default.aspx?c=10&Version=22#3250)

          SSDI Manual version 2.1 (https://www.naaccr.org/wp-content/uploads/2021/09/SSDI-Manual_v-2.1-2022.pdf?v=1658434004)

          • Hematologic Malignancies section, Plasma Cell Myeloma schema 00821
              June - Reportability Update: Intraepithelial Neoplasias and ACR Reporting and Data Systems ("-RADS") Imaging Categories

          This month’s tip contains some recent reportability updates and clarifications from SEER, and it should replace any outdated information in previous Quality Tip e-mails.

          Intraepithelial Neoplasias

          Starting 1/1/2021, all intraepithelial neoplasia/lesions with a behavior code of /2 in ICD-O 3.2 are reportable to SEER and UCR, with a few exceptions* (see below).

          Intraepithelial neoplasias with a behavior code of /0 in ICD-O 3.2 remain NON-reportable.  

          Some reportable examples (not a complete list):

          • 8077/2 Anal Intraepithelial Neoplasia (AIN) II, AIN III or AIN II-III, also known as ASIN-H (high-grade anal squamous intraepithelial neoplasia)
          • 8077/2 Vulvar or Vaginal Intraepithelial Neoplasia (VIN/VAIN) II,  VIN/VAIN III, or VIN/VAIN II-III
          • 8148/2 Biliary intraepithelial neoplasia, high grade
          • 8071/2 Differentiated-type vulvar intraepithelial neoplasia (dVIN) or well-differentiated vulvar intraepithelial neoplasm
          • 8071/2 Differentiated penile intraepithelial neoplasia (PeIN)

          Some NON-reportable examples (not a complete list):

          • 8077/0 Anal intraepithelial neoplasia, low grade
          • 8077/0 Squamous intraepithelial neoplasia, grade I
          • 8148/0 Glandular intraepithelial neoplasia, low grade

          If a particular diagnosis is not specifically listed in ICD-O 3.2, NAACCR’s Annotated Histology List, or SINQ (see References below), submit it to Ask-A-SEER-Registrar (https://seer.cancer.gov/registrars/contact.html) to confirm reportability.  Do not assume similar-sounding histologic terms are equivalent.

          *Reportability exceptions

          Per SEER Manual, these diagnoses remain NON-reportable:  

          • Cervical intraepithelial neoplasia (CIN) or squamous intraepithelial neoplasia (SIN) of the cervix (C530-C539)
          • Prostatic intraepithelial neoplasia (PIN)
          • Squamous intraepithelial neoplasia (SIN) of all skin sites (C44._)

          Per ICD-O 3.2 update materials (see References below) – not reportable until 2022 and forward:

          • 8163/2 Papillary neoplasm, pancreatobiliary type, with high grade intraepithelial neoplasia

          American College of Radiology Reporting and Data Systems (“-RADS”) imaging categories

          SEER has recently updated SINQs # 20210037 and 20210075 to clarify reportability of these, as follows:

          The following cancer cases ARE reportable unless there is information to the contrary

          • Liver cases with an LI-RADS category LR-4 or LR-5
          • Prostate cases with a PI-RADS category 4 or 5

          The following are NOT reportable without additional information

          • Breast cases designated BI-RADS 4, 4A, 4B, 4C or BI-RADS 5
          • Lung cases designated Lung-RADS 4A, 4B, or 4X
          • Liver cases based only on an LI-RADS category of LR-3
          • Colon cases with only C-RADS information (C-RADS category C4 is not reportable by itself)
          • Head and Neck cases with only NI-RADS information (NI-RADS category 3 is not reportable by itself)
          • Ovarian or fallopian tube cases with only O-RADS information (none of the O-RADS categories are reportable without additional information)
          • Thyroid cases with only TI-RADS information (none of the TI-RADS categories are reportable without additional information)

           

          References

              May - Coding Primary Site for Solid Tumors: Priority of Source Documents

          CODING PRIMARY SITE FOR SOLID TUMORS:  priority of source documents

          The 2022 SEER Manual instructs as follows:

          Resources for Coding Primary Site for Solid Tumors, in priority order

          • ICD-O (topography/site codes haven’t changed, unlike recent updates to morphology/histology codes)
          • SEER Program Manual
            • Including Coding Guidelines in Appendix C
          • Solid Tumor Rules

          Appendix C of the SEER Manual contains priority lists for various source documents in the Bladder, Breast, and Colon modules.

          The Solid Tumor Manual has additional priority instructions in the Head and Neck, Central Nervous System (CNS), and Urinary modules.  

          Both of the above have helpful anatomic diagrams, tips, and terminology tables for several sites, which can assist with selecting the most accurate code.  

          The main SEER Manual also contains guidelines for coding primary site in cases of transplanted organs, occult tumors of the head and neck, sarcomas, unknown primaries with CancerTYPE ID testing, and other specific situations.

          Coding Examples:

          • Endoscopy describes a tumor in the descending colon, biopsied and tattooed; pathology report final diagnosis is “Left colon mass at 56 cm, biopsies:  adenocarcinoma”.  Subsequent hemicolectomy operative report findings:  tattoo ink was visible in the splenic flexure and underlying tumor was palpable.  Path report gross description states tumor is in descending colon, 4 cm from proximal margin; final diagnosis “Left hemicolectomy:  adenocarcinoma”.
            • There are multiple potential site codes among the different source documents – descending/left colon C18.6, “56 cm” C18.7, and splenic flexure C18.5.  Per SEER Manual Appendix C, the operative report has highest priority for coding primary site, so the correct code is C18.5.
            • Note:  for colon, even 4th character sub-site differences (Cxx._) could affect the number of potential subsequent primaries, per Solid Tumor rule M9.
          • CT scan shows abnormal neoplastic tissue in retropharyngeal area and adenoids (C14.0, C11.1, or C14.8); laryngoscopy describes mass originating in the fossa of Rosenmuller (C11.2).  Procedure note and path report from biopsy state “nasopharyngeal mass” NOS (C11.9), moderately differentiated squamous cell carcinoma.  Case is presented at head and neck tumor conference with the consensus diagnosis of squamous cell carcinoma of posterior nasopharynx (C11.1), T1N0M0, with recommendation for radiation and chemotherapy only.  Patient completed this treatment, with radiation treatment summary specifying the target volume as nasopharynx (C11.9).
            • Correct primary site is C11.1 per specialty tumor board, according to the Solid Tumor Manual Head and Neck module, priority order for identifying primary site.

          Key Point:  accurate assignment of primary site code varies by cancer type, and requires detailed abstract text documentation of the associated source records, which may include tumor conference notes, operative report findings, or physician statements describing procedures done at outside facilities.  

          BONUS MINI-TIP/REMINDER:  Rounding numeric values

          General rounding rules from the Site Specific Data Items (SSDI) Manual:

          If digit is 0-4, round down:  example – PSA lab value of 7.42 ng/ml, round down to 7.4 to fit the format of the PSA Site-Specific Data Item (SSDI) code.

          If digit is 5-9, round up:  example – tumor size of 4.5 mm, round up to 5 mm (code 005) to fit the Tumor Size data items format.

          Exception for breast primaries (per SEER Manual):  Round tumor sizes greater than 1.0 mm and up to 2.4 mm, to 2 mm (code 002), to derive the correct AJCC TNM Primary Tumor (T) category for breast primaries. Do not apply this instruction to any other site.  

          Example:  breast lumpectomy path report states invasive carcinoma is 1.2 mm in greatest dimension, margins clear.  Code Tumor Size Pathologic as 002.

           

          References:

              April - Text Substantiation for EOD and Summary Stage of Date Items

          TEXT SUBSTANTIATION FOR EXTENT OF DISEASE (EOD) AND SUMMARY STAGE DATA ITEMS

           

          At UCR, CTR editors who check submitted abstracts for acceptable quality have access to some original source documents such as pathology and selected imaging reports, but no routine access to physician notes, TNM forms, or treatment plans to verify staging codes.  If there is insufficient support in the abstract text for EOD or Summary Stage items, UCR editors may be forced to change codes that were submitted by the abstractor.

          Example of poor documentation from an actual abstract received at UCR:

          2021 Lung carcinoma case.  Scans Text:  1/22/2021 BRAIN MRI - 5 MM LESION INVOLVING CORTEX OF RT FRONTAL LOBE, FINDING RAISES CONCERN FOR A SMALL METASTATIC LESION; PROBABLE METASTATIC OSSEOUS LESION INVOLVING LT FRONTAL SKULL.

          Staging Text:  M1C (BONE AND BRAIN METS) STAGE IVB.

          • No treatment plan was documented.  There is no indication of whether the M1c was assigned by the physician or the registrar, or whether “bone and brain mets” was taken from a statement made by the physician.  
          • Only EOD--Mets code 30 (Single extrathoracic metastasis in a single organ [bone]) or M1b is adequately substantiated in the text documentation, because “probable” is a reportable ambiguous term from the scan.  “Raises concern for” is not reportable terminology, and there is no clear indication that the physician interpreted that language as evidence of brain mets.

           

          Example of better documentation from an actual abstract received at UCR:

          2020 Esophagus carcinoma.  Scans Text:  10/10/2020 ANGIO PULMONARY CT - WALL THICKENING IN DISTAL ESOPHAGUS, MALIGNANCY IS DIFFICULT TO EXCLUDE.  

          1/12/2021 PET - ACTIVITY IN LOWER 1/3 OF ESOPHAGUS, MAXIMAL THICKNESS 1.6 CM, NO EVIDENCE OF THORACIC OR ABD METS.

          Scopes Text:  12/29/2020 UPPER ENDOSCOPY - ESOPHAGUS: CIRCUMFERENTIAL ESOPHAGEAL MASS FROM 35-40 CM, CONSISTENT WITH MALIGNANCY. MULTIPLE BIOPSIES OBTAINED. THE MOST DISTAL 2 CM OF ESOPHAGUS WAS NORMAL.

          Path Report:  WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA, DEPTH OF INVASION CANNOT BE DETERMINED.

          Staging Text:  CLINICAL T3 (PER PHYSICIAN NOTE) N0 (NO LYMPHADENOPATHY) M0 (NO METS) STAGE IIB.

          • There was no further workup documented and no surgery; radiation and chemo were the only treatments.  EOD—Primary Tumor was submitted as code 350 (Adventitia and/or soft tissue invaded).
          • Without the text documenting “per physician note”, there would be no clear substantiation for cT3, or EOD—PT code 350.  Code 200 (Localized, NOS) is the furthest extent that would be adequately supported.  Code 200 would change the Summary Stage and the Derived EOD codes that are sent to SEER by central registries, making Summary Stage 1/Localized, and our Derived EOD T1N0M0 Stage Group I.
          • Ideally, additional information from the physician note regarding his/her basis for assigning cT3 would be included in the abstract text.  

          Key Points: 

          • Most users of cancer registry data will not have access or time to read through patients’ medical records for verification of unsubstantiated staging codes.  Simply copying the staging codes into the abstract text without additional supporting details is against standards defined in the NAACCR Data Dictionary.  
          • Detailed text documentation to substantiate staging codes is crucial, especially physician confirmation of ambiguous or unclear information.  Otherwise, codes may be changed or excluded from data uses where they could provide critical information.

          References (excerpts):

          SEER EOD Manual General Instructions page 9, Ambiguous Terminology:  When it is not possible to determine the extent of involvement because terminology is ambiguous, look at the documentation that the physician used to make informed decisions on how the patient is being treated…The clinician’s definitions/descriptions and choice of therapy have priority over these [ambiguous terminology] lists because individual clinicians may use these terms differently.  https://seer.cancer.gov/tools/staging/eod/general-instructions.pdf 

          NAACCR Data Dictionary, item #2600 Text--Staging:  Text is needed to justify coded values and to document supplemental information not transmitted within coded values.  Text automatically generated from coded data is not acceptable.  If information is missing from the record, state that it is missing.  Some suggestions for text:  Date(s) of procedure(s), including clinical procedures, that provided information for assigning stage; Physician's specialty and comments.  https://apps.naaccr.org/data-dictionary/ 

              March - Reportability and Date of Diagnosis Based on "-RADS" Imaging Classification

          Reportability and Date of Diagnosis based on “-RADS” imaging classifications

          The American College of Radiology has developed standardized criteria frameworks called RADS (Reporting and Data Systems) for radiologists to use in imaging reports.  In 2018, the SEER Manual began including in its Appendix E some examples of “-RADS” categories that are reportable versus non-reportable, and more examples have been added in recent updates.  

          For the reportable –RADS categories, the manual instructs to code the date of the scan as the date of diagnosis, when it’s the earliest confirmation of malignancy.

          Coding Examples: 

          • Chest imaging on 10/17/2021 shows a 2 cm solid nodule in left lung with abnormal mediastinal lymph nodes, classified as Lung-RADS 4X.
            • Lung-RADS categories are not reportable per SEER Manual Appendix E; do not report this case if this is the only documentation available.
            • Even if further testing confirms lung cancer, do not use the Lung-RADS scan date as the date of diagnosis.  Code the earliest date of the reportable test that diagnosed the cancer.
          • A 9/25/2021 pelvic MRI shows a 3 cm mass arising from prostate with extra-prostatic extension and mass effect on rectum; PI-RADS 5.  Core biopsy on 10/7/2021 confirms adenocarcinoma in the prostate.
            • Code Date of Diagnosis as 9/25/2021 per the MRI, SEER Manual Appendix E, and SINQ 20170023.
            • Remember that for prostate, the MRI findings cannot be used to code EOD-Primary Tumor, per its associated coding Notes:  “Imaging is not used to determine the clinical extension. If a physician incorporates imaging findings into their evaluation (including the clinical T category), do not use this information.”

          The SEER Inquiry System (SINQ) also provides some additional information – see the full questions below for more details:

          20210037  Thyroid imaging reporting and data system (TI-RADS) 5 is reportable; TI-RADS 4 (including 4a and 4b) is not reportable

          20210033  For liver, a “LI-RADS-Treatment Response (LR-TR) viable nodule” is not reportable            

          Key Point:  Guidelines vary for reportability of different -RADS categories based on primary site.  If you come across a –RADS term not covered in Appendix E of the SEER Manual or in SINQ, submit a question to Ask A SEER Registrar (https://seer.cancer.gov/registrars/contact.html).

          BONUS MINI-TIP/REMINDER:  to assist in coding EOD-Primary Tumor for melanomas, if Clark level is not stated on the pathology report or mentioned in physician notes, it can be estimated based on Breslow depth using the following guidelines from Note 4, and the Summary Stage 2018 Manual’s Skin chapter:

          Level I (In situ)

          Level II (< 0.75 mm Breslow’s Depth)

          Level III (0.76 mm to 1.50 mm Breslow’s Depth)

          Level IV (> 1.50 mm Breslow’s Depth)

          Level V (through entire dermis)

          References:  

          2021 SEER Manual Appendix E - https://seer.cancer.gov/archive/manuals/2021/SPCSM_2021_Appendix_E.pdf 

          ACR Reporting and Data Systems (RADS) information page - https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems 

          SEER Registrar Staging Assistant, site-specific schemas including EOD Notes - https://staging.seer.cancer.gov/eod_public/list/2.1/ 

          SEER Summary Stage 2018 Manual, Skin chapter - https://seer.cancer.gov/tools/ssm/SSM2018-SKIN.pdf

              February - Prostate Extent of Disease-Primary Tumor

          PROSTATE EXTENT OF DISEASE–PRIMARY TUMOR (NAACCR Item #772)

          For localized prostate cancers, SEER Extent of Disease-Primary Tumor (EOD-PT) depends on whether the tumor is clinically apparent, meaning palpable on digital rectal exam (DRE).

          EOD-PT codes 100-250 for clinically inapparent tumor REQUIRE either:

          • Documentation of DRE findings that meet the criteria described in the EOD-PT coding Notes on SEER*RSA, or
          • Documentation of physician’s clinical T assignment

          There are no exceptions to the above criteria; if they are not met, code 300 for Localized NOS must be assigned.  

          Key Point:  For EOD-PT, registrars cannot assume the tumor was inapparent because a biopsy was stated to be done for elevated PSA, or because there is no information to indicate that tumor was apparent.  There must be clear documentation of DRE findings, or that a physician assigned a clinical T1 category.  These are the guidelines for EOD, and they may differ from other staging systems. 

          Coding Examples:  

          • Patient is seen at facility ABC for radiation treatment due to recent diagnosis of prostate cancer on core biopsy by urologist.  There is no mention of DRE findings, but the radiation oncologist stages the tumor as cT1c N0 M0.
            • Code EOD-Primary Tumor as 120 and document in the abstract text that tumor was staged cT1c per physician.
          • Patient comes to facility XYZ for a prostatectomy, having been previously diagnosed with prostate cancer on biopsy in a physician office.  Surgeon’s pre-op notes document that an elevated PSA of 7.3 ng/ml prompted the biopsy, and that staging scans were negative for metastatic disease.  No further information is available.
            • Code EOD-Primary Tumor as 300, localized NOS, since neither DRE findings nor physician TNM is available.

          Reference:  SEER*RSA Prostate schema, EOD-Primary Tumor Notes 4, 5 and 6 (https://staging.seer.cancer.gov/eod_public/input/2.1/prostate/eod_primary_tumor/?breadcrumbs=(~schema_list~),(~view_schema~,~prostate~) ).

          • Specifically, Note 4, 5th bullet:  “Code 300 for localized cancer when it is unknown if the tumor is clinically apparent. This would include cases with elevated PSA and positive needle core biopsy but no documentation regarding tumor apparency (inapparent versus apparent). Another example would be a diagnosis made prior to admission for a prostatectomy with no details provided on the initial clinical findings.”
          • Note 6, Example:  “DRE reveals prostate is ‘firm.’ Physician stages the patient as a cT2a. The T2a can be used since the physician has documented this.”
              January - Coding Birth Surname

          CODING BIRTH SURNAME

          Effective 01/01/2021, both SEER and NPCR implemented requirements for a new data item, Birth Surname (NAACCR #2232).  This is a gender-neutral replacement for the previous Maiden Name field (NAACCR #2390 Name--Maiden).  UCR requires Birth Surname from all reporting facilities.

          This field should be coded regardless of gender or marital status.  

          Coding Instructions:

          • Truncate name if longer than 40 characters
          • Record when known regardless of value in the Sex data item
          • Leave blank if the birth surname is not known or not applicable
          • Blank spaces, hyphens, and apostrophes are allowed; do not use other punctuation

          Birth Surname can aid cancer registries in patient matching and de-duplication, and is used at the state/central registry level for automatic race and ethnicity calculations via NHIA (NAACCR Hispanic Identification Algorithm) and NAPIIA (NAACCR Asian/Pacific Islander Identification Algorithm).

          Coding Examples

          • Married female patient completes hospital registration form as follows:  
            • First Name – Eva
            • Middle Name – L.
            • Last Name – Baker
            • Maiden or Birth Surname – Tua’one
            • Emergency contact – spouse, Jennifer Baker
              • Code Birth Surname as TUA’ONE
          • 26 year old single male patient completes hospital registration form as follows:
            • First Name – Michael
            • Middle Name – John
            • Last Name – Young
            • Maiden or Birth Surname – blank
            • Emergency contact – sister, Julie Moore
            • A note in his clinical history states he was adopted at age 3.
              • Leave Birth Surname blank, since it is unknown whether Young is his adoptive family’s surname or his birth surname.

          References:

          SEER Program Coding and Staging Manual 2021, page 31 (https://seer.cancer.gov/archive/manuals/2021/SPCSM_2021_MainDoc.pdf )

          NAACCR version 21 Required Status Table  (https://apps.naaccr.org/data-dictionary/)

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