Post on 30-Apr-2020
Centers for Disease Control and PreventionNational Program of Cancer Registries
Atlanta, Georgiawww.cdc.gov/cancer/npcr
NPCR Education and Training Series (NETS)Module 4: The Value of Accurate Text in Cancer
RegistryPrepared by Scientific Applications International Corporation (SAIC)
CDC Contract Number 200–2002–00576–0004
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The Value of Accurate Text in Cancer Registry
Using 2007 Multiple Primary and Histology Coding Rules
October 21, 2008
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Purpose of Standardized Data
Consistency
Monitor patient trendsObserve referral patternsAllocate resources
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Importance of Standardized Data
Data Collection
Required data setsResearchMarketingFuture data requestsSpecial studiesAvoiding “unknowns”
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Codes vs. Supporting Text
WOMEN MEN
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Resolving Coding Discrepancies
Compare information
Hospital #1 – Patient J.R. Race: 01 White Hospital #2 – Patient J.R. Race: 02 Black
Hospital #3 – Patient M.P. C504 2 Left Hospital #4 – Patient M.P. C504 1 Right
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NAACCR Standards – Supporting Text
Standard 3.2.2 – Data Text
Text information should be:
included in the registry’s dataset
transmitted along with codes when tumor records are shared with other registries.
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Ambiguous Terms1
Diagnostic of cancer
Consistent withFavor (s)Most likelyPresumedProbableSuspect (ed)Suspicious (for)Typical (of)
1 www.seer.cancer.gov
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Ambiguous Terms1
Cases Diagnosed 1/1/1998 or later
Diagnostic of cancer
AppearsComparable withCompatible withMalignant appearing
1 www.seer.cancer.gov
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Ambiguous Terms2
NOT diagnostic of cancer
EquivocalPossibleQuestionableSuggestsWorrisomeCannot be ruled outRule (d) outPotentially malignant
2 www.seer.cancer.gov
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Purpose of Text
Defensive abstracting Unusual occurrencesEdit check verificationRecoding auditsResearcher useFacility useRe-abstraction of historical data
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Purpose of Text
Defensive abstracting
Unusual occurrences
Edit check verification
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Purpose of Text
Recoding audits
Researcher use
Facility use
Re-abstraction of historical data
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MCR PERFORMS 100% VISUAL REVIEW OF ALL CASES IN “PREP PLUS”
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MCR CHECKING THE ERRORS
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LOOKING FOR TEXT FIELDS IN PREP PLUS
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MCR TRYING TO MAKE THE CALL
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Validating Codes with Text
What is important? Defines who, what, when and where Example:Description of code(s)2/10/07 Date of diagnosisBF 40 y/o black, non-Hispanic
femaleC504 Upper outer quadrant of breast /2 Behavior code for in situ8500 Histology code infil ductal ca
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Supporting Text
Date of birth (year)SexRaceHispanic originTumor markersPrimary siteLateralityHistology/behaviorGrade/differentiation
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Supporting Text
Tumor sizeCS ExtensionCS LNSRegional LNS positive and examinedCS Mets at DxSite-specific factors 1–6Operative reportsTreatment modalitiesFollow-up and recurrence
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Examples of Validating Codes with Text
Patient demographic codes:Race code: 02Hispanic code: 0Sex code: 2
Patient demographic text:“B/F, non Hispanic”
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Examples of Validating Codes with Text
Cancer ID and stage codes
Primary site: C341Histology: 8140Behavior: /3Grade: 2Tumor size: 020Laterality: 1Regional LNs positive: 00Regional LNs examined: 03
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Examples of Validating Codes with Text
Cancer ID and stage pathology text
8/7/2007: Lobectomy of the right upper lobe lung reveals a moderately differentiated invasive adenocarcinoma measuring 2cm in greatest diameter. Three hilar lymph nodes are removed and are negative for carcinoma. Margins are negative.
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Examples of Validating Codes with Text
Abbreviated text :
8/7/2007: Lobectomy RUL lung: mod diff inv adenoca. TS 2cm. 3 hilar LN removed, neg for ca. Margins neg.
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Examples of Validating Codes with Text
Procedure: 30 – LobectomyPrimary site: C341 – RUL lungHistology: 8140 – adenocaBehavior: /3 – malignantGrade: 2 – MDTumor size: 020 – 2cm Laterality: 1 – rtRegional LNS positive: 00 – 00/03Regional LNS examined: 03 – 00/03Margins: 0 – margins neg.
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Facility-specific Documentation
Facility-specific information
Medical record number: 548528Date of admission: 8/3/2007Date of discharge: 8/8/2007Hospital number: 625007- Medical CenterClass of case: 1 – Dx and tx here Insurance: 60 – Medicare
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Examples of Validating Codes with Text
First course treatment information
Surgery primary site: 22 – LumpectomyScope LNS surgery: 2 – SLN BxChemotherapy: 87 – RefusedRadiation therapy: 7 – RefusedDate hormone tx: 07/10/07Hormone therapy: 01 – Administered
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Examples of Validating Codes with Text
Follow-up and recurrence
Type last tumor follow-up: 01 – ReadmitVital status: 1 – AliveRecurrence type: 00 – None/disease-free
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NAACCR-Approved Abbreviations3
Adenoca: AdenocarcinomaAnt: AnteriorBil: BilateralCa: CarcinomaCont: ContinueDz: DiseaseDx: DiagnosisExc: Excision
3 www.naaccr.org
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NAACCR-Approved Abbreviations
Lg – LargeMets – Metastatic, MetastasesRx – TreatmentSx – SymptomsTx – TreatmentW/ – WithW/O – WithoutW/U – Workup
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NAACCR-Approved Symbols
@ At / Comparison< Less than, decrease= Equals> Greater than, increase - Negative+ Positivex Times
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Context-Sensitive Abbreviations
Use carefullyAP Anteroposterior; Abdominal perinealBM Bone marrow; Bowel movementCA Carcinoma; CalciumMIN Minimum; MinuteML Middle lobe; MilliliterMM Multiple myeloma; Millimeter PAP Papillary; Papanicolaou smear PT Patient; Physical therapyRT Right; Radiation therapy SCC Small cell carcinoma; Squamous cell
carcinoma
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Documentation in the Abstract
Codes Race 01Sex 2Primary site C343Histology/Behavior 8070/3Grade 3Surgery 30Chemotherapy 03Follow-up cancer status 1
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Documentation in the Abstract
Text Race: black Sex: female Primary site: upper outer quadrant breastHistology: ductal carcinoma, in situLaterality: left Surgery: lumpectomy Hormone: hormone therapy administeredCancer status: no evidence of this tumor
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Documentation in the Abstract
Required fields with textPrimary site: C341 – lung right upper lobe
RUL lungHistology: 8140 – adenocarcinomaBehavior: /3 – malignantGrade: 2 – moderately differentiatedTumor size: 020 – TS 2cm in sizeLaterality: 1 – right RtRegional LNS positive: 00 – noneRegional LNS examined: 03 – three
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Documentation in the Abstract
Final abstract
Codes and text provide information on the patient and the patient’s disease
Either should derive the same outcomeText should be concise and pertinent Use only approved abbreviationsCodes provide universal language for
data retrieval
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Helpful Hints for Abstracting
Document the information that led to the assignment of a particular codeC619 – Prostate gland
Document in the appropriate area in the abstract
Do not duplicate informationDocument what you know; do not
make assumptions
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Visual Editing
Self-editingReread your abstract without the
supporting documentsCentral registry editingVisual editingMajor versus minor errorsMajor error: 8140 instead of 8500Minor error: Colon CS ext 15 instead of 14
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Visual Editing
Can improve abstracting skills and improve data quality through
Self-editingCentral registry editingDepartmental editing
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Summary
Provide text for all required fields using approved abbreviations to support codes being documented within the abstract.
Perform visual editing of the abstract to validate the correct use of the codes and text provided.
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IN CLOSING:
C.Y.A.
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C.Y.A. MEANS:
C= COVERY= YOURA= ABSTRACT
DOCUMENT…DOCUMENT…DOCUMENT
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