1. Coding Pitfalls Jessica K. Dohler, BS, CTR

2. Objectives 0 Know how to code the Tumor/Ext Eval code when using intraoperative findings 0 Know when to code “none” vs. “unknown” by using the Inaccessible LN Rules 0 Understand the 2012 FORDS Grading guidelines changes 0 Understand the limitations of imaging in prostate staging

3. TS/Ext Eval 1 or 3 Is information on an operative report TS/Ext eval code 1 or 3?

4. TS/Ext Eval 1 or 3 Eval Code Choices for OP Findings Eval Code 1 - ClinicalEval Code 3 - Pathologic 0 No surgical resection done. 0 Invasive techniques or surgical observation without biospy 0 Surgical resection performed without neoadjuvant txt 0 Based on evidence acquired before txt supplemented or modified by evidence acquired during & from surg

5. TS/Ext Eval 1 or 3 Scenario – Exam and Op Findings 0 CT of abdomen & colonoscopy negative 0 Operative findings – sigmoidectomy & right oophorectomy Bulky colon mass extends into retroperitoneum Peritoneal seeding Thickened and suspicious right ovary

6. TS/Ext Eval 1 or 3 Scenario – Pathology Report 0 Sigmoid colon and upper rectum Signet ring cell adenocarcinoma, high grade Invades through muscularis propria into subserosal fat Proximal & distal margins negative Radial margins, positive/involved 0 Ovary – negative for tumor 0 Path staging pT3 pN2a 5/21 LN involved

7. TS/Ext Eval 1 or 3 Summary: Op Findings vs. Path Report 0 Op Findings Tumor extends outside colon into retroperitoneum CS Ext code 675, maps to T4b 0 Path Report Subserosal fat, radial margin positive CS Ext code 400, maps to T3 (also stated by pathologist) Which takes precedence?

8. TS/Ext Eval 1 or 3 Eval Code Choices for OP Findings Eval Code 1 - ClinicalEval Code 3 - Pathologic 0 No surgical resection done. 0 Invasive techniques or surgical observation without biospy 0 Surgical resection performed without neoadjuvant txt 0 Based on evidence acquired before txt supplemented or modified by evidence acquired during & from surg

9. TS/Ext Eval 1 or 3 What Eval Code to Use? 0 We know to code the extension to 675 since it is the most extensive 0 Eval code 1 since info is from the op findings (observation during surgery)? 0 Eval code 3 since there was a resection done?

10. TS/Ext Eval 1 or 3 Scenario Answer 0 Correct eval code is 3 – pathologic 0 Rationale Supplemented/modified by evidence aquired during and from surgery Use information from op findings since nothing in path overrides this information Pathologist did not receive any tissue for the retroperitoneum  NOTE: op findings without surgical resection would be eval 1.

11. TS/Ext Eval 1 or 3 References 0 CS v0204 Coding Instructions Part I Section 1, page 41 #7 – Explanation of code 1 #8 – Explanation of code 3

12. Inaccessible Lymph Nodes Coding “None” vs. “Unknown”

13. Inaccessible Lymph Nodes What are they? 0 Inaccessible lymph nodes are those that cannot be easily examined during a physical exam or observation. 0 They are located within body cavities and cannot be palpated. 0 Some primary sites with inaccessible lymph nodes Bladder, colon, uterus, lung, liver, ovary, kidney, prostate and stomach

14. Inaccessible Lymph Nodes What’s the rule? 0 Move to code “none” rather than “unknown.” 0 Three conditions must be met: No mention of regional LN involvement on PE, imaging or surgical exploration Patient has clinically low stage (T1,T2 or localized) disease. Patient receives or is offered the usual treatment for node negative primary site disease.

15. Inaccessible Lymph Nodes Scenarios 0 84 y/o male has 2.2cm LUL mass on CT, LN not mentioned. 0 CT guided needle biopsy positive for adenoca. 0 Patient not a surgical candidate due to comorbidities. 0 Patient received steriotactic surgery to LUL mass only. No chemo recommended. Do you code CS LN to 000 or 999? Correct answer = 000

16. Inaccessible Lymph Nodes Scenarios 0 69 y/o male with elevated PSA at 4.9. 0 DRE WNL 0 Prostate bx shows adenocarcinoma in 2/12 cores. Gleason score 3+3=6. 0 MD stages T1c 0 Patient undergoes prostate seed brachytherapy radiation alone. Do you code CS LN to 000 or 999? Correct answer = 000

17. Inaccessible Lymph Nodes Scenarios 0 58 y/o female with chest pain and shortness of breath. 0 CT shows a 9.2cm mass in the RUL, no mention of LN. 0 CT guided biopsy of mass positive for SQCCA. 0 Patient receives radiation and refuses chemo. Do you code CS LN to 000 or 999? Correct answer = 999

18. Inaccessible Lymph Nodes Scenarios 0 62 y/o male with elevated PSA at 36.2. 0 DRE WNL 0 Prostate bx shows adenocarcinoma in 6/12 cores with extracapsular extension. Gleason score 3+3=6. 0 Patient undergoes prostate seed brachytherapy radiation and hormone therapy. Do you code CS LN to 000 or 999? Correct answer = 999

19. Inaccessible Lymph Nodes References 0 CS v0204 Coding Instructions Part I Section 1, page 5 – Documenting Negative Lymph Nodes and Distant Metastases Part I Section 1, page 21 – Inaccessible Lymph Nodes Rule

20. Grade Differentiation 2012 Changes

21. Grade Differentiation 2012 Changes 0 Entire Morphology: Grade section of FORDS has been changed 0 Jan 2012 Cases – CoC no longer supports site specific grade conversion 0 SSF grading fields take precedence 0 Hierarchy of guidelines for coding morphology grade differentiation

22. Grade Differentiation Guidelines 1. Hematopoietic and Lymphatic Grades Code in Grade/Differentiation field All must be coded to 5-8 or 9 Code according to Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual Leave Grade Path System and Grade Path Value fields blank

23. Grade Differentiation Guidelines 2. Special Grades Code in Collaborative Staging SSF fields Code all SSF grade fields according to specific CS instructions in CS Manual Part 1 Section 2 Gleason, Furhman, WHO, Nottingham or Bloom- Richardson Code Grade/Differentiation field as 9 Leave Grade Path System and Grade Path Value fields blank

24. Grade Differentiation Guidelines 3. Grade Path System and Grade Path Value Other than hematopoietic and lymphatic or special grade Documented in numeric form AND number of grades in system known DO NOT convert verbal description to numeric codes Code Grade/Differentiation field as 9

25. Grade Differentiation Guidelines 4. All Others Grade cannot be coded according to rules 1 through 3 See table on page 12-13 of FORDS for complete list of verbiage/code conversion

26. Grade Differentiation Scenarios 0 LN Bx: Follicular lymphoma, grade 2 Look in Hematopoeitic Database Grade/Differentiation = 6 Grade Path System = Blank Grade Path Value = Blank

27. Grade Differentiation Scenarios 0 Prostate Bx: Adenocarcinoma in 5/12 cores. Gleason 4+3=7. Grade/Differentiation = 9 Grade Path System = Blank Grade Path Value = Blank Prostate SSF 7 = 043 Prostate SSF 8 = 007

28. Grade Differentiation Scenarios 0 TURB: High Grade Urothelial Carcinoma In Situ Grade/Differentiation = 9 Grade Path System = Blank Grade Path Value = Blank Bladder SSF 1 = 020  Per notes assume term high grade is a WHO Grade

29. Grade Differentiation Scenarios 0 Sigmoid Colon Bx: Adenocarcinoma. Grade 2 of 2. Grade/Differentiation = 9 Grade Path System = 2 Grade Path Value = 2

30. Grade Differentiation Scenarios 0 Breast Lumpectomy: Well differentiated ductal carcinoma. Bloom-Richardson score 4. Nuclear Grade 1/3. Grade/Differentiation = 1 Grade Path System = 3 Grade Path Value = 1 Breast SSF 7 = 040

31. Grade Differentiation References 0 FORDS 2012 Manual Section One – Overview of Coding Principles Morphology: Grade, Pgs 10-13

32. Prostate Imaging Can I use imaging to determine if cancer is apparent or inapparent?

33. Prostate Imaging Inapparent vs. Apparent 0 DRE – gold standard for staging Used to determine inapparent (not felt) or apparent (felt) 0 Imaging – TRUS, MRI, CT Not used for staging unless managing physician confirms Not used due to limitations (too often results incorrect) Interobserver variability Lack of sensitivity and specificity

34. Prostate Imaging CS Extension Table Notes & Clarification Note 3A: 0 A clinically apparent tumor is palpable or visible by imaging. Clarification: No list of words for imaging that determine if visible. Only the clinician/managing physician can interpret. 0 If a clinician documents a "tumor", "mass", or "nodule“, this can be inferred as apparent. Clarification: CS got permission to use these words for the clinician, which only applies to the DRE. The words cannot be used for imaging.

35. Prostate Imaging Coding Scenarios Patient has an elevated PSA and benign DRE per MD note. MRI report states the result as T2c. No managing MD stage. What is the CS Extension code? 0 CS Extension Code = 150 Since there is no managing MD stage the MRI report was not supported by the managing physician. Therefore code 150. Clinically inapparent tumor. Bx done for elevated PSA

36. Prostate Imaging Coding Scenarios Unknown if DRE performed. No documented pre-bx PSA. MRI report states T2a prostate tumor. No managing physician stage. What is the CS Extension code? 0 CS Extension Code = 300 Since there is no documented DRE or physician statement it is unknown why the biopsy was performed. It is unknown if the tumor is apparent or not. Best to use the NOS code.

37. Prostate Imaging Coding Scenarios Elevated PSA. Benign DRE. MRI shows nodule occupying greater than half of left lobe. Managing MD stage is T2. What is the CS Extension Code? 0 CS Extension Code = 220 Although the managing MD T stage is T2nos it is safe to code to cT2b since it is obvious that MD stage is based upon the MRI which specifically shows greater than half of one lobe involved with tumor.

38. Prostate Imaging References 0 CS v0204 Coding Instructions Part II, Prostate Schema, page 44

39. THANK YOU!!!!