Bradley W. Schenck, copyright ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER

Bradley W. Schenck, copyright ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER

ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER Recoding Audit Performed in 2009 260 cases audited 17 data items audited per case 4420 possible discrepancies 277 discrepancies identified Overall Accuracy Rate: 94% Accuracy Rate Goal: 97%

ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER Problematic Data Items 50% of all discrepancies occurred among five data items (in descending order): CS Site Specific Factor #6(invasive component) CS Lymph Nodes Grade Histology CS Tumor Size

ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER Excellence Can be Achieved by Concentrating on Four Areas: 1. Text documentation No text documentation Poor text documentation Impacted CS Site Specific Factor #6

ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER 2. CS Lymph Nodes Code 000 versus Code 999 Code 250 versus Code 260 Code 000 versus involved lymph node code 3. Grade Volume 1, Section V.3.5.8 Priority for grade when Bloom Richardson is unknown

ACHIEVING EXCELLENCE IN ABSTRACTING BREAST CANCER 4. Multiple Primary and Histology Rules H12: Ductalcarcinoma and more specific duct carcinoma H17: Ductalcarcinoma mixed with other types of carcinoma

ABSTRACTING COACH Meet the Abstracting Coach

DOCUMENTATION Documentation Volume 1, Section 1.6.3 Coding Codes must be supported by text documentation on the abstract.

SSF 6 INVASIVE COMPONENT Code indicates how the pathological tumor size is coded in CS Tumor Size Mixed indicates a tumor with invasive and in situ components Pure indicates a tumor that contains only invasive or only in situ components

SSF 6 INVASIVE COMPONENT In Situ Terms Noninfiltrating Intraepithelial Intraductal without infiltration Lobular neoplasia Review the Pathology Report Carefully and Clearly Document Findings

SSF 6 INVASIVE COMPONENT Example of Coding SSF 6 Pathology: Infiltrating ductalcarcinoma, moderately differentiated with extensive intraductalcomponent; invasive CA measures 0.4 cm. Code 020 -Both in situ and invasive components present and size of invasive component is stated.

SSF 6 INVASIVE COMPONENT Example of Coding SSF 6 Mammogram: Spiculatedmass in left breast at 12 o'clock. Ultrasound: 2.2 cm mass highly suggestive of malignancy. Code indicates path tumor size Pathology: Biopsy (+) for infiltrating ductal carcinoma with aprocine features, and DCIS. Code 987, Clinical tumor size coded.

CS LYMPH NODES 000 VS. 999 Inaccessible Lymph Nodes Rule for Regional Lymph Nodes: For inaccessible lymph nodes, record CS Lymph Nodes as Code 000 (None) rather than Code 999 (Unknown) when the following three conditions are met: 1. There is no mention of regional lymph node involvement in the physical examination, pretreatment diagnostic testing or surgical exploration. 2. The patient has clinically low stage (T1, T2, or localized) disease.

CS LYMPH NODES 000 VS. 999 3. The patient receives what would be usual treatment to the primary site (treatment appropriate to the stage of disease as determined by the physician) or is offered usual treatment but refuses it, since this presumes that there are no involved regional lymph nodes that would otherwise alter the treatment approach. Code 999 can and should be used in situations where there is reasonable doubt that the tumor is no longer localized and there is no documentation of involved regional lymph nodes. CS Manual, Part 1

CS LYMPH NODES 000 VS. 999 Example of Coding CS Lymph Nodes 000 PE: Mass in LOQ right breast, no palpable lymph nodes Excisionalbiopsy: Invasive lobular carcinoma, TS; 1.5 cm., margins clear CS Lymph Nodes: Code 000 clinically negative lymph nodes and localized disease

CS LYMPH NODES 000 VS. 999 Example of Coding CS Lymph Nodes 999 PE: Lungs clear Left breast biopsy: Lesion at 3:00 position Pathology: Moderately differentiated infiltrating ductal and intraductal carcinoma. TS: 0.7 cm Port-A-Cathplacement CS Lymph Nodes: Code 999, no information regarding regional lymph nodes, chemotherapy planned

ASTRACTING COACH: CS LYMPH NODES 250 VS. 260 Code 250 Movable axillarylymph node(s), ipsilateral, positive with more than micrometastasis Code 260 Stated as N1, NOS

CS LYMPH NODES 250 VS. 260 Warning! Inferring Lymph Node Involvement From Stated N Category: If the information in the medical record is ambiguous or incomplete regarding the extent that the tumor has spread, lymph node involvement may be inferred from the N category as stated by the physician. CS Manual, Part 1 Use the physician stated N category only after a thorough search for more specific information

CS LYMPH NODES 250 VS. 260 Example of Coding CS Lymph Nodes 250: Pathology: Infiltrating ductalcarcinoma, grade 2, 6/9 points. Axillarysentinel lymph node (+): 1/1. Axillarylymph nodes(+): 2/6 by IHC. Tx, N1, M0 = stage 2A per AJCC staging form CS Lymph Nodes: Code 250, Breast Schema, CS Lymph Nodes, Note 2. Code 260 is used in cases in which N1 documented by physician is the only information available.

GRADE Use BR grade if available! Volume 1, V.3.5.8 Bloom-Richardson Grade for Breast Cancer Synonyms include: Modified Bloom-Richardson Scarff-Bloom-Richardson Nottingham SBR Grading BR Grading Elston-Ellis modification of Bloom-Richardson

GRADE Use grade or differentiation information from the breast histology in the following priority order: Bloom-Richardson (Nottingham) scores 3-9 converted to grade (see conversion table) Bloom-Richardson grade (low, intermediate, high) Nuclear grade only Terminology (well diff, mod diff ) Histologic grade (grade I, grade ii )

GRADE Bloom-Richardson Conversion Table Bloom- Richardson Score Bloom- Richardson Grade Nuclear Grade Term Histo Grade Code 3-5 Low 1/3, 1/2 Well Diff BR Low Grade 1 6, 7 Intermediate 2/3 Mod Diff BR Interm. Grade 2 8, 9 High 2/2, 2/3 Poorly Diff BR High Grade 3

GRADE In this grading system, the terms low, intermediate, and high are codes 1, 2, and 3 respectively In the Bloom-Richardson system, if grades 1, 2, and 3 are specified, these should be coded 1, 2, and 3 respectively CAUTION!

GRADE Example of Coding Grade Pathology: Needle biopsy. Infiltrating ductal carcinoma BR score 8/9. Lumpectomy with sentinel lymph node biopsy and axillarylymph node dissection; TS 4 cm, high grade infiltrating ductalcarcinoma involving pectoralismuscle; 4/33 axillary lymph nodes positive. Grade: Code 3, Bloom-Richardson 8/9 = 3, per Volume 1, Section V.3.5.8

GRADE Example of Coding Grade Pathology: Lumpectomy. Multiple foci of ductal carcinoma in invasive cribiformcarcinoma, low grade. Grade code: Code 2, Volume 1, Section V.3.5; low grade, NOS = 2

HISTOLOGY - H12 AND H17 Multiple Primary and Histology Rules H12: Duct carcinoma, NOS and a more specific duct carcinoma Specific histology may be identified as: Type, Subtype Predominately With features of, major, or with differentiation Architecture and pattern (in situ only)

HISTOLOGY H12 AND H17 Multiple Primary and Histology Rules H17:Combination of duct and any other carcinoma Use Table 2 in MP/H Manual, Breast, to identify duct carcinomas Other carcinomas and any duct carcinoma listed on Table 1 or Table 2

HISTOLOGY H12 AND H17 Table 1 Intraductal(8500/2) and Specific Intraductal Carcinomas Most common specific intraductal carcinomas Column 1: Code Column 2: Type 8201 Cribiform 8230 Solid 8401 Apocrine 8500 Intraductal, NOS 8501 Comedo 8503 Papillary 8504 Intracystic 8507 Micropapillary/Clinging

HISTOLOGY H12 AND H17 Table 2 Duct (8500/3) and Specific Duct Carcinomas Most common specific intraductalcarcinomas Column 1: Code Column 2: Type 8022 Pleomorphic carcinoma 8035 Carcinoma with osteoclast-like giant cells 8500 Duct, NOS 8501 Comedocarcinoma 8502 Secretory carcinoma of breast 8503 Intraductalpapillary adenocarcinoma with invasion 8508 Cystic hypersecretory carcinoma

HISTOLOGY H12 AND H17 SEER SINQ 20091130 Question: How are the following two examples coded? Infiltrating ductal carcinoma, mucinous type Infiltrating ductalcarcinoma with features of tubular carcinoma Answer: The infiltrating ductaltypes in Rule H12 are listed (8022, 8035, 8501-8508) and do not include mucinousnor tubular. This rule cannot be applied. The first rule that applies to these single tumors is H17, code to histology code 8523, infiltrating duct mixed with other types of carcinoma.

HISTOLOGY H12 AND H17 Question: SEER SINQ 20091085 What is the correct histology code for this breast cancer case? Final diagnosis says, "Infiltrating duct carcinoma with apocrine features." What rule is used? Answer: Assign histology code 8401/3 (apocrine adenocarcinoma) according to rule H12. Apocrineis a type of duct carcinoma (see Table 1). Code 8401 should be listed in Rule H12. Apocrineshould be removed from Table 3.

CS TUMOR SIZE Three Site-Specific Codes: 996 -mammographic/xerographic diagnosis only, no size given; clinically not palpable 997 -Paget s Disease of nipple with no underlying tumor 998 - diffuse

CS TUMOR SIZE Neoadjuvant Treatment Planned or Administered If the patient receives preoperative (neoadjuvant) systemic therapy (chemotherapy, hormone therapy, immunotherapy) or radiation therapy, code the farthest involved regional lymph nodes based on information prior to surgery. CS Manual, Part 1 Example: Patient has a hard matted mass in the axilla (code 510) and a needle biopsy of the breast that confirms ductalcarcinoma. Patient receives three months of chemotherapy. The pathology report from the modified radical mastectomy shows only scar tissue in the axillawith no involvement of axillarylymph nodes (Negative, code 000). Code CS Lymph Nodes as 510 because prior to treatment they appeared to be clinically involved.

CS TUMOR SIZE Example of Coding CS Tumor Size PE: Left breast, at 2:00 a 2.8 cm malignant appearing mass. Pathology: Biopsy. Infiltrating ductalcarcinoma, suspicious for lymphatic invasion. Pre Surgery Chemotherapy Pathology: Segmental mastectomy. Infiltrating ductal carcinoma small cell subtype, grade 2, tumor size 1.5 cm. Ductalcarcinoma, solid type, tumor size 2.0 cm. Margins clear. Chemotherapy effect present.

CS TUMOR SIZE Example of Coding CS Tumor Size (continued) CS Tumor Size, code 028, clinical tumor size. CS Manual, Part 1, states, If the patient receives preoperative (neoadjuvant) systemic therapy (chemotherapy, hormone therapy, immunotherapy) or radiation therapy, code the farthest involved regional lymph nodes based on information prior to surgery.

CS TUMOR SIZE Example of Coding CS Tumor Size (continued) Pathology: Needle core biopsies of calcifications microscopic foci of in situ ductalcarcinoma CS Tumor Size, code 990; microscopic focus or foci only. CS Manual, Part 2, Breast schema, CS Tumor Size

CS TUMOR SIZE Example of Coding CS Tumor Size (continued) Mammogram and magnified views: 1 cm solid nodule left breast at 2:00; no other findings Specimen radiograph confirms successful excision. Palpable mass in middle of specimen Pathology: Lobular carcinoma in situ with Pagetoid spread into duct CS Tumor Size, code 010. No tumor size mentioned on pathology, use radiography tumor size

COACH S ABSTRACTING CHECKLIST

COACH S ABSTRACTING CHECKLIST Code selected for SSF #6 is related to the pathological tumor size for CS Tumor Size Follow the inaccessible lymph node rule in the CS Manual, Part 1, when regional lymph nodes are not removed Use the physician stated N category only after a thorough search for more specific information Follow Volume 1, V.3.5.8 when coding grade

COACH S ABSTRACTING CHECKLIST In coding histology, rule H12 is applied when there is a duct carcinoma, NOS and a more specific duct carcinoma In coding histology, rule H17 is applied when there is a combination of duct and any other carcinoma Apocrine is a type of duct carcinoma, see Table 1. Code 8401 should be listed in Rule H12. Apocrine should be removed from Table 3.

COACH S ABSTRACTING CHECKLIST SEER Program Coding And Staging Manual

COACH S ABSTRACTING CHECKLIST C50.0 Nipple (areolar) Paget disease without underlying tumor C50.1 Central portion of breast (subareolar) area extending 1 cm around areolarcomplex Retroareolar, Infraareolar Next to areola, NOS Behind, beneath, under, underneath, next to, above, cephaladto, or below nipple Paget disease with underlying tumor

COACH S ABSTRACTING CHECKLIST C50.2 Upper inner quadrant (UIQ) of breast Superior medial Upper medial Superior inner C50.3 Lower inner quadrant (LIQ) of breast Inferior medial Lower medial Inferior inner

COACH S ABSTRACTING CHECKLIST C50.4 Upper outer quadrant (UOQ) of breast Superior lateral Superior outer Upper lateral C50.5 Lower outer quadrant (LOQ) of breast Inferior lateral Inferior outer Lower lateral

COACH S ABSTRACTING CHECKLIST C50.6 Axillarytail of breast Tail of breast, NOS Tail of Spence

COACH S ABSTRACTING CHECKLIST C50.8 Overlapping lesion of breast Inferior breast, NOS -Inner breast, NOS Lateral breast, NOS -Lower breast, NOS Medial breast, NOS -Midline breast NOS Outer breast NOS - Superior breast, NOS Upper breast, NOS 3:00, 6:00, 9:00, 12:00 o clock

COACH S ABSTRACTING CHECKLIST When to Use Subsite8: Code the Primary Site to C50.8 when: There is a single tumor that overlaps two or more subsites, and the subsite in which the tumor originated is unknown There is a single tumor located at the 12, 3, 6, or 9 o clock position on the breast

COACH S ABSTRACTING CHECKLIST When to Use Subsite9: Code the Primary Site to C50.9 when: There are multiple tumors (two or more) in at least two quadrants of the breast There are multiple tumors (two or more) in at least two quadrants of the breast There is inflammatory carcinoma without palpable mass

CONTINUING EDUCATION INFORMATION To Receive CEU Hours: Complete the short Breast Module Quiz located at: http://www.classmarker.com/embedded_quizzes /?quiz=f65840869ba31a35dd56c66352849b74 Copy entire address into your web browser This is an external web site, quiz results will be automatically emailed to Katheryne Vance, BA, CTR, Education and Training Coordinator

ACKNOWLEDGEMENTS National Cancer Institute, SEER Program Cover art by Bradley W. Schenck, copyright used with permission