module 4: the value of accurate text in cancer registry · the value of accurate text in cancer...

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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