1. What’s the Diff? Sue C. Vest, CTR Missouri Cancer Registry This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Missouri Department of Health and Senior Services (DHSS) (#U55/CCU721904) and a Surveillance Contract between DHSS and the University of Missouri.

2. Acknowledgements Jeannette Jackson-Thompson, MSPH, PhD Nancy Cole, CTR Deborah Smith, CTR Louanne Currence, RHIT, CTR Chester Schmaltz, Graduate Research Asst. All other registrars who offered comments and suggestions

3. Objectives Determine if the use of 8010 rather than 8000 is a good quality indicator. Identify ways coding uniformity can be improved in facilities and central registries.

4. WHY!! Reaction to CDC National Program of Cancer Registries (NPCR) QI reports Percentage of cases coded to 8000-8005 is NOT a good QI indicator Diagnostic confirmation Reporting Source (Death Clearance Only (DCO)) Clear guidelines on how to code non-specific histology are lacking

5. What? Discussions Restricted Access File MCR data review Survey Poster presentation at NAACCR 2006

6. % Non-specific Morphology [420] All Sites Combined*, Both Genders Individual State Registries and NPCR Registries Combined, 2001 diagnosis year

7. MCR Stats – by Dx Confirmation

8. MCR Stats – Reporting Source

9. NPCR Restricted Access File (RAF) Record level 1999-2002 data 37 states meeting NPCR publication criteria (= NAACCR silver certification) 358,960 cases Limited release (2 states applied in ’05)

10. NPCR RAF Data

11. Death Clearance Only Cases 8000 – 8005 range = 3.98% - 96.7% 8010 range = 0.00% - 68.67% All other histology range = 3.30% - 46.43% Based on 1999-2002 data from NPCR RAF (37 states, 4,289,696 cases)

12. NPCR RAF Data

13. Non-microscopically Confirmed 8000-8005 Range = 15.93% - 83.48% 8010 Range = 0.00% - 52.70% Other Range = 15.74% - 40.84% Based on 1999-2002 data from NPCR RAF (37 states, 4,289,696 cases)

14. Survey Info Demographics Trainings/conferences attended Case scenarios Excerpts from hospital cases Non-hospital cases Death Certificate Only (DCO) cases

15. Survey Results # of responses = 40 Place of employment 45% hospital 45% central registry 10% other (vendor/contractor/consultant) CTR = 40 Attended conferences/workshops = 40

16. Survey Questions

17. Survey Case Scenario #2 LEFT KIDNEY: Poorly differentiated malignant neoplasm with … See comment. COMMENT #1: The differential diagnosis includes poorly differentiated renal cell carcinoma and a renal sarcoma such as synovial sarcoma. The pathologic material is being referred for consultation and a final report will follow (no final report available in chart). 8000=87.5% (35) 8010=2.5% (1) 8312=10.0% (4)

18. Case Scenario #3 CT:…poorly defined area of decreased enhancement suggesting pancreatic head mass. Onc. consult: obstructive jaundice with pancreatic mass very suggestive of pancreatic cancer. Await the cytology from biliary drainage, as well as ca-19-9. It will likely be difficult to establish the diagnosis. Discharge summary diagnosis: 1. Pancreatic mass, likely pancreatic cancer. 8000 = 67.5%(27) 8010 = 17.5%(7) N/R = 12.5% (5)

19. Survey Case Scenario #4 Non-hospital case Lung primary with mets to liver and skeleton. Patient treated with radiation at unknown facility. 8000 = 67.5% (27) 8010 = 30.0% (12)

20. Case Scenario #5 Non-hospital case (nursing home): Prostate cancer. No stage given. Observation only 8000 = 65% (26) 8010 = 17.5% (7) 8140 = 12.5% (5) N/R = 2.5% (1)

21. Case Scenario #6 Non-hospital case (nursing home): 2 x 5 cm mass in right outer breast. Patient refused biopsy. Diagnosed with mammogram. Treated with Tamoxifen. 8000 = 57.5% (23) 8010 = 27.5% (11) 8500 = 2.5% (1) N/R = 10% (4)

22. Case Scenario #9 Death Certificate Only case Cause of death = Metastatic breast carcinoma 8000 = 12.5% (5) 8010 = 82.5% (33) 8500 = 2.5% (1)

24. ICD-O-3 Morphology 8000/3 – Neoplasm, malignant Tumor, malignant NOS Malignancy Cancer Unclassified tumor, malignant Blastoma, NOS 8010/3 – Carcinoma, NOS Epithelial tumor, malignant “often (incorrectly) used interchangeably”

25. Other Guidelines I & R “…Can we assume if a physician does not state carcinoma, 8000/3 should be used?” FORDS “codes for cancer, NOS and carcinoma, NOS are not interchangeable” SEER Inquiry …abbreviation “ca” = ???

26. Effective QI Tool? Maybe!! Coding of 8010 must have supporting documentation Reporting source and diagnostic confirmation must be considered

27. Conclusions Need more info to answer the questions Is the use of more specific histologies a good QI indicator? Are there adequate guidelines for determining when to use 8000-8005 histology codes?

28. Lessons Learned More definitive guidelines needed Training Review of non-specific histologies and carcinoma coding Edits??

29. Thank you Questions? Sue C. Vest, CTR vests@health.missouri.edu http://mcr.umh.edu