Finding Cases for Low Volume Hospitals This training is provided by the Missouri Cancer Registry MCR gratefully acknowledges Louanne Currence, RHIT, CTR who developed the Power Point presentation used as the basis for this training and Debra Douglas, CTR who developed the policies and procedures for cancer reporting by low volume hospitals. Disclaimer- Missouri Cancer Registry presents this training as a learning tool for hospital staff who report cancer cases to the central registry. This tool should not be used to determine medical diagnoses. Persons seeking CMEs or CEUs should check with their accrediting organization to determine if this training meets their criteria for educational credits. 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) (#U58/DP ) and a Surveillance Contract between DHSS and the University of Missouri.

There are several Missouri laws about cancer reporting. Missouri Cancer Registry (MCR) Regulations Reporting of cancer cases to the Missouri Department of Health (now the Missouri Department of Health and Senior Services) for Missouri hospitals became mandatory in 1984 when the State General Assembly passed a bill to require inpatient reporting by hospitals. Due to changes in the health care delivery system, an increasing number of cancer cases are now being treated outside the hospital setting. Therefore an expanded cancer reporting law was passed in 1999 (RSMo , , , and CSR [pdf]). This law requires that pathology laboratories, ambulatory surgery centers, freestanding cancer clinics and treatment centers, physicians and long-term care facilities also report cancer cases CSR [pdf]

The laws are applied to low-volume facilities as follows: A hospital with 75 or fewer cases annually is classified as low volume. Low volume facilities: –Identify potential cases, copy and submit relevant parts of the medical record for abstraction by central registry staff. –Submit cases on a quarterly basis. –Submit cases to MCR within 6 months of patient’s initial contact with the facility.

The main role of low volume hospitals is case finding & submitting charts in a complete and timely fashion. By law, facilities are required to report cases diagnosed and/or treated for cancer in their facility. Unlike larger hospitals, low volume hospitals are not required to submit fully-abstracted cases electronically. Related duties involve keeping complete records of cases submitted, correspondence from MCR, etc.

Case-Finding Basics Designate a specific person to perform case- finding and allow adequate time to identify cases, copy and submit charts. Conduct case-finding activities on a regular basis at least quarterly. Collaborate with the laboratory and other departments/sources that may provide tumor information.

How do I identify reportable cases?

Reportable Cases ●Inpatient and outpatient hospital cases are required ●Cases with specified ICD-9 codes In order to report a case to MCR, you first must be able to determine if a case is eligible. Case eligibility is usually determined by a combination of factors, which include the behavior of the disease (benign, malignant, in situ, etc.), and when and where the case is treated. Look in the MCR Abstract Code Manual or on the MCR website for a reportable list of the ICD-9 codes ( 9-CM%20Low-Volume%20Codes.pdf). 9-CM%20Low-Volume%20Codes.pdf The following slides discuss different aspects of how to determine if you should report a case to MCR.

If your facility owns the medical record you should report the case! The general rule of thumb is that the hospital that owns the medical record where the patient’s diagnosis and/or treatment occurs is the facility required to report the case. For many low volume facilities, the patient will be diagnosed in your facility, but referred elsewhere for treatment. Examples: A patient has a mammogram at your hospital and the radiologists says the test is suspicious for breast cancer. The patient is referred to another hospital for the biopsy. This case is reportable. A patient has a colonoscopy at a surgery center owned by the hospital. The test shows cancer. This case is reportable. A patient is diagnosed with prostate cancer by a prostate biopsy performed in a physician’s office whose practice is owned by your hospital. This case is reportable.

ICD-9-CM Inclusions and Exclusions While the ICD-9-CM list mainly includes malignancies, there are a few inclusions and exclusions you need to know.

Inclusion: Benign brain tumors are reportable Beginning with cases diagnosed in 2004 benign brain tumors are required to be reported to MCR. Codes for benign brain tumors that must be reported are: ICD-9-CM Codes – (for Benign Meninges and Brain) – (for Spinal Cord, Cranial Nerves and other) – (for other endocrine glands, etc.)

Exclusions: Some malignant tumors are NOT reportable. Basal Cell Carcinomas (BCC) and Squamous Cell Carcinoma (SCC) of the skin are no longer required to be reported. This includes ICD-9-CM codes – skin cancers. MCR does not require CIN (cervix) ICD-9-CM 233.1, PIN (prostate) ICD-9-CM

Tricky cases!! Cases of intraepithelial neoplasia can be tricky. MCR does require intraepithelial neoplasia for all AIN (anal) ICD-9-CM code – 154.3, Female Genital Organs – which includes VIN (vulvar) and VAIN (vaginal) and Male Genital Organs –

Some terms used in reporting cases can be ambiguous. Terms that designate a reportable case must always include a reference to malignancy, cancer or other similar term, except when the diagnosis is for a benign primary tumor of the intracranial region, the brain or the central nervous system. Some specific ambiguous terms that are used by physicians constitute a reportable diagnosis, while others do not. These terms may originate from any source document such as pathology, radiology, discharge summary and clinical reports and may lead to minor problems during case finding as some ambiguous terms for ICD-9 coding may not mean the same thing regarding reporting status (i.e.: ‘possible’ cancer may be coded as a malignancy by ICD-9 coders, but ‘possible’ is a non-reportable ambiguous term for cancer reporting). When reviewing the medical record, if ambiguous terminology is used in the diagnosis, refer to the following list to determine reporting status.

Some terms used in reporting test results can be ambiguous. If one of the following terms is used by the physician (in combination with “malignancy” or “cancer”), the case is reportable: On the other hand, if one of these terms is used, the case is NOT reportable: apparentlycompatible withmalignant appearingprobable appears toconsistent withmost likelytypical of comparable withfavorspresumedsuspicious cannot be ruled outpotentially malignantsuggests equivocalquestionableworrisome possiblyrule out

Examples of Ambiguous Terminology CT scan results state “cancer cannot be ruled out.” This is NOT reportable. CT scan results state “probable cancer.” This is reportable.

What sources do I use to identify cases?

Common places to look for reportable cases include: To identify reportable cases, it is essential to identify potential sources. Medical Records/HIM departments: These departments can produce lists based on the patient’s diagnosis (ICD-9 codes) and/or the type of procedure done for the patient (CPT codes). These lists are commonly called medical records disease indices (MRDI). Laboratory reports: Pathology reports from surgical procedures are a good source. Cytology reports from urine, sputum, fluids such as spinal, pleural, ascites, etc. are also good sources to use when looking for reportable cases. Pap tests are considered cytology, but MCR does not require results from those procedures. Outpatient department lists: Patient lists from outpatient sites such as same day surgery clinics, satellite clinics, etc. can provide possible reportable cases. Clinic charts must be reviewed at least annually, but it may be easier to do it more often (monthly or quarterly).

The MRDI is one of the most complete sources to locate reportable cases. It must be designed to include codes to identify all potential cases based on ICD-9-CM DIAGNOSIS CODES. For each admission of the patient include THE TOP SIX ICD-9 CODES (see MCR Abstract Code Manual or the MCR website for list of reportable codes) and reviewed on a regular basis (at least quarterly). Do not rely on non-specific activities such as discharge lists, memory or charts being identified by coders. The report should be designed to include patient name, date of birth, ICD-9-CM codes, procedure codes, admission type and medical record number and sorted by patient name. If your department does not have the capability to generate the report, request assistance from your hospital’s IT department. Using the Medical Record Disease Index (MRDI) to locate cases

Using the pathology report to locate cases The use of pathology reports will identify patients diagnosed and or treated at your facility. Collaborate with staff in the pathology department to route copies of all path reports that mention a reportable diagnosis. Provide pathology department personnel with the necessary information to identify cancer cases. Some facilities may have electronic pathology records that could be used to produce regular reports.

Other Sources Outpatient listings –Same-day surgery centers –Satellite clinics ***Occasionally you will run across a chart that provides evidence of a diagnosis in a physician’s office. Cases generated by a patient having been seen in a physician’s office (not owned by the hospital) ONLY are optional to report at this time.

Other potential sources: –Specialty procedures for patients (such as colonoscopies, bronchoscopies or orchiectomies) that have a special procedure code. You should be able to ask for a report (at least annually) of patients receiving these procedures. Potential sources (continued)

What constitutes a diagnosis?

A diagnosis includes: Positive pathology reports - examination of tissue and blood. –Tissue specimens - incisional biopsy, excisional biopsy, surgical resection, autopsy and D&C –Bone Marrow biopsy – aspiration and biopsy –For leukemia only – Peripheral blood smears, CBCs, WBCs

What constitutes a diagnosis? Positive cytology reports - examination of cells –Bronchial brushings and washings, sputum smears, pleural fluid, peritoneal fluid, spinal fluid, gastric fluid, cervical and vaginal smears, urinary sediment (Pap tests are considered cytology, but MCR does not require results from those procedures.)

Diagnosis continued: Positive radiology tests – these tests may contain ambiguous terminology & may require additional manpower for review. Mammograms Chest x-rays CT scans MRIs Ultrasound

How do you define treatment?

Definition of treatment Treatment or therapy for cancer modifies, controls, removes or destroys cancer tissue. The first course of treatment includes all cancer-directed treatments indicated in the initial treatment plan which are actually delivered to the patient. A decision not to treat or refusal by the patient to accept treatment is considered a treatment plan, as is palliative care. These patients are all reportable to MCR.

Examples of treatment Reportable During a colonoscopy at another facility a patient is diagnosed with colon cancer. The patient has a part of the colon removed at your facility. The patient is admitted to your facility during a course of chemotherapy for low blood counts. During the hospital stay, the patient receives chemotherapy.

Exclusions – these are not reportable: Not reportable A patient is diagnosed with colon cancer at another hospital. He comes to your facility for a follow-up annual colonoscopy. A patient is receiving chemotherapy at another hospital/facility. Due to complications or another health condition, the patient is hospitalized at your facility. The patient is coded as having a “history of cancer” in ICD-9. Your facility is caring for a patient who has active or metastatic cancer but is not receiving treatment but may be receiving hospice care for the cancer at your facility.

Keeping Track… A Control Log of charts that have been submitted to MCR must be maintained. This log should include: –Patient name –Date of birth –Social security number –Reporting year –ICD-9 codes –Encounter date(s) –Date submitted to MCR

Other Documentation Copies of pathology reports, new patient listings, end of treatment notes, monthly/quarterly disease index and other logs and discrepancy files may be maintained as desired by the facility. All case-finding files should be secured per HIPAA regulations to prevent unauthorized access to patient information.

Use of a “non-reportable” list To further assist with case-finding activities and possibly eliminate the need to pull a chart multiple times, a non- reportable list can be maintained. This is a list of cases that have been reviewed and found to be non-reportable. This list should include: –Patient name –Date of birth or social security number –Encounter date(s) –ICD-9 codes –Brief reason case is non-reportable

Key Elements to Remember 1.Identify potentially reportable patients 2.Locate the charts and other data 3.Review for reporting status 4.Copy pertinent chart documents for reportable cases 5.Transmit the data to MCR at least quarterly 6.Maintain suspense and control logs

In Summary Case-finding should be considered a priority of the Health Information Management (or other designated) department. A specific person should be designated to perform case- finding. That person should be given adequate time to identify, copy and submit charts. Case-finding activities must be conducted on a regular basis (at least quarterly). MCR must be informed of any staff turnover or changes.

And don’t forget --- A Transmittal Form must be submitted for each reporting period (quarterly) even if no charts are being sent. Please contact MCR if data submission for any reporting period is going to be late. Call MCR at with questions – we’re glad to help!!