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From Abstract to From Abstract to Audit and Back Audit and Back AgainAgain
Nancy RoldMissouri Cancer Registry
MoSTRA Annual Meeting 2010
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/DP000820-04) and a Surveillance Contract between DHSS and the University of Missouri.
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To see ourselves as others see us,would from many a blunder free us.
-Robert Burns
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OutlineOutline
Review Results◦National NPCR audit◦NPCR audit of MCR data◦MCR audits of hospital data
Strategies to Use◦Field specific recommendations to avoid occasional traps and pitfalls
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National NPCR AuditNational NPCR AuditCompared select abstract data fields to source documents for all sites from 28 states
Cases diagnosed 2004-2006
Overall accuracy by state was 90-98% - Excellent!
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NATIONAL NPCR AUDITNATIONAL NPCR AUDIT
CS Elements Errors by Diagnosis Year
Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis
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NATIONAL NPCR AUDITNATIONAL NPCR AUDIT
Surgery Errors by Diagnosis Year
Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis
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NPCR Audit of NPCR Audit of MCRMCR Data DataIn 2008, with the help of 9 Missouri
hospitals of varying size - Thank you!!
NPCR re-abstracted 297 MCR cases diagnosed in 2005 for Quality in 20 critical data fields
Casefinding was also audited to assess data for Completeness
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NPCR Audit of NPCR Audit of MCRMCR Data Data
Overall data accuracy for Missouri was 95%
Overall completeness was 96.7%
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NPCR Audit of NPCR Audit of MCRMCR Data Data
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
99.7% 98.7% 97.6% 96.0% 95.3%94.3% 93.6% 93.6% 93.6% 93.6%
88.2% 84.8%
73.1%
Accuracy Rates for Tumor-Specific Elements
Source: NPCR Data Completeness and Quality Audit of Missouri Cancer Registry – Diagnosis Year 2005
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NPCR Audit of NPCR Audit of MCRMCR Data Data
Sites with the highest error rates ◦Lung 20%◦Breast 19%◦GI & Urinary15%
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MCR Audits of MCR Audits of HospitalHospital DataDataMCR tries to audit every hospital within a 5 year cycle
Audits may include casefinding and/or re-abstraction/re-coding
Again, Thank You for participating!
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MCR Re-Abstraction - MCR Re-Abstraction - SourcesSources2007 Hospital Data
Abstracts From Recent Transmittal(s)
Text - Source Document
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MCR Re-Abstraction - MCR Re-Abstraction - OutcomesOutcomesPrimary Sites
Breast - Highest Incidence of Errors (10%)
Colorectal (8%)
Lung (6%)
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MCR Re-Abstraction - MCR Re-Abstraction - OutcomesOutcomesField Coding Errors
CS Extension Highest Incidence of Errors (11%)
Grade, CS LNs, Rx Surgery Summary (10% Respectively)
Primary Site/Subsite, Dx Date (9% Respectively)
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MCR Re-Abstraction - MCR Re-Abstraction - RecommendationsRecommendations
Enter Supporting Text Into the Abstract First Then Code the Data Items
Review Codes and Text Carefully to Ensure Each Substantiates the Other• Be Specific When Assigning Codes • Look Twice Before Assigning 9’s
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MCR Re-Abstraction - MCR Re-Abstraction - ConclusionConclusion
Text to Code Auditing will be one of MCR’s standard audit methods
Keep in mind Supporting Text is required as explained in previously published MCR guidelines and now in the MCR Manual
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MCR MCR CasefindingCasefinding Audit - Audit - PurposePurposeAffirm Case Completeness of Electronic Reporting Facilities – 2007 data
Special Emphasis on Evaluation of New Multiple Primary rules
Evaluate Hospital Casefinding Procedures, Patterns
Provide Education
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MCR Casefinding Audit - MCR Casefinding Audit - SourcesSources
Twenty Facilities Reviewed - High, Medium, Low Categories
2007 MRDI Provided By Facility
2007 MCR Extract File Of Hospital Data
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MCR Casefinding Audit - MCR Casefinding Audit - OutcomesOutcomes
Overall Results Were Very Good 95-100%
Fifteen Hospitals Met the Standard
1 Hospital Was 100% Complete!! 2 Hospitals Missed Only One Case!
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MCR Casefinding Audit - MCR Casefinding Audit - FindingsFindings
Overall Case Completeness
Facility Type
Match Cases
Missed Cases
Matched & Missed
Per Cent Complete
All Total 5,092 218 5,310 95.89
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Body System Number of
Found Cases Number of
Missed Cases Number Found
and Missed Percentage
Case Completeness
Respiratory System 1,057 33 1,090 96.97
Breast 825 28 853 96.72
Digestive System 952 26 978 97.34
Male Genital System 449 25 474 94.73
Endocrine System 110 17 127 86.61
Miscellaneous 93 17 110 84.55
HP Diseases 110 14 124 88.71
Non-Malignant CNS 106 13 119 89.08
Lymphoma 223 12 235 94.89
Reportable Skin 126 11 137 91.97
Female GU System 325 11 336 96.73
Urinary System 344 7 351 98.01
Oral Cavity / Pharynx 170 1 171 99.42
Bones and Joints 11 1 12 91.67
Brain / Nervous System 88 1 89 98.88
Myeloma 58 1 59 98.31
Soft Tissue / Heart 32 0 32 100
Eye and Orbit 4 0 4 100
Mesothelioma 9 0 9 100
Total 5,092 218 5,310 95.89
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Casefinding – Casefinding – Types of Missed CasesTypes of Missed Cases
Clinically Diagnosed casesCases Diagnosed On Imaging
Cases Diagnosed on Biopsy Encounters for XRT, Chemotherapy, Hormonal Therapy
Majority Outpatient Cases
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Casefinding - Reasons for Casefinding - Reasons for Missed CasesMissed Cases
Pathology Reports / OP Treatment Summaries Not Routed to Registry
No MRDI Review Inadequate MRDI ReviewIncomplete ICD-9 and Service Codes on MRDI
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Casefinding - Casefinding - RecommendationsRecommendationsDo Not Limit Casefinding to Pathology Reports or Treatment Summary Referrals
Develop a Medical Record Disease Index
Run Separate MRDI’s To Capture Benign Brain/CNS Cases and Op Rx Cases
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Casefinding - Casefinding - RecommendationsRecommendationsBe cognizant of
timeliness/completeness reminders
Notify MCR of late file submissions
Encourage electronic casefinding enhancements when feasible
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CS Extension - ColonCS Extension - ColonPath: MD adenocarcinoma extending
through the subserosa into the pericolic fat
Code: 450 – Extension to pericolic fat
Not: 400 – Subserosal fat invaded or 420 – Fat, NOS
Source: CS Colon Schema
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CS Extension - BladderCS Extension - Bladder
Path: Transitional cell carcinoma, non-invasive
Code:010- stated non-invasive
Not300 - localized, NOS
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CS Extension - ProstateCS Extension - ProstateH&P: PSA elevated, DRE unremarkable,
biopsy recommended & done, stated cT1
Code: 150 – tumor identified by needle biopsy, e.g. for elevated PSA, clinically inapparent
Not999 – extension unknown
See CS schema notes – registrar should not infer whether tumor is apparent
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CS – SSF 3 - ProstateCS – SSF 3 - ProstateCode based on first course
prostatectomy or autopsy findings, not the clinical findings coded in CS Extn
970 – no prostatectomy (RT consult notes may confirm this)
960 – unknown if prostatectomy doneAvoid use of 030 – Localized, NOS
when a more specific code applies (230 - both lobes)
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CS – SSF 3 - ProstateCS – SSF 3 - Prostate
Path: Gleason 7 adenocarcinoma with extracapsular extension and positive margins
Code: 480 – extracapsular extension and positive margins
Not: 420 – unilateral extracapsular extension
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CS Extension - LungCS Extension - LungRadiologic evidence of Pleural
Effusion was not properly coded as CS Extn 72 in several findings in the NPCR audit of MCR 2005 data.
NOTE: in 2010 pleural effusion is coded in CS Mets at DX (codes 15-18) for lung primaries and in SSF1 for Pleura primaries.
Read the CS coding notes carefully relative to your case.
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CS Extension - ThyroidCS Extension - Thyroid
Path: two areas of papillary carcinoma in left thyroid lobe
Code: 200 - Multiple foci confined to thyroid
Not: 300 – local, NOS
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CS Extension vs. MetsCS Extension vs. Mets
Op Note/Path: Lung cancer with direct extension into adjacent rib
Med Onc note: surgeon found rib mets
Code: CS Extn 730 – Adjacent ribNot: Mets at Dx 40
Text, Text, Text – to support
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CS Lymph Nodes – Lung CS Lymph Nodes – Lung
CT scan: mediastinal mass suspicious for LN involvement
Code : 200 – Mediastinal, NOSNot: 999 - Unknown
For other terms that constitute clinical diagnosis of LN, see CS Manual, part 1section 1, pg 23.
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CS Mets CS Mets 999 – Unknown may be an over-
used code000 should be used if the cancer
is stated to be early stage and tx is for such
Example: Localized lung cancer treated with surgery alone.
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CS Mets CS Mets
For standard treatments by stage see:
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
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Site - MeningesSite - Meninges
MRI of brain – probable meningioma
Site Code: C70.0 cerebral meninges
Not: C71.0 cerebrum
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Subsite - BreastSubsite - Breast
On the NPCR audit of MCR data, breast accounted for 60% of the subsite discrepancies.
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Subsite - BreastSubsite - Breast
Used by permission: April Fritz, A Fritz and Associates, LLC
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Subsite - BreastSubsite - BreastC50.8
Single tumorOverlaps contiguous subsitesPoint of origin unknown
C50.9Multiple tumorsOrigins in different subsites of one breast, orNOS
Source: FORDS p. 107, ICD-O-3 p. 25
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Subsite - BreastSubsite - Breast
Use of C50.9 - NOS may be a result of the lack of availability in the medical record.
Source: MCR data extract, Use of C50.9 by class of case in abstracts 2004-2008 as % of total breast sites.
Class 0 Class 1 Class 2 Class 3 overall
17% 15% 24% 60% 20%
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C50.9 - MCR DataC50.9 - MCR Data
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Histology – Colon PolypsHistology – Colon Polyps
Path: adenocarcinoma within a tubulovillous adenoma
Code: 8263 – Adenocarcinoma in a tubulovillous adenoma
Not: 8140 – Adenocarcinoma, NOS
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Histology - Colon PolypsHistology - Colon Polyps
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Histology - ThyroidHistology - Thyroid
Path for thyroid surgery: papillary carcinoma
Code: 8260 – papillary carcinoma (C73.9)
Not: 8050 – papillary carcinoma, NOS
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Grade – Bladder (historic)Grade – Bladder (historic)Path: papillary urothelial
carcinoma, low gradeCode:
2 – moderately differentiatedNot:
1 – well differentiatedSimilarly high grade was coded to
04 undifferentiatedBUT….
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Grade – Bladder – NEW!Grade – Bladder – NEW!August I&R question 48073:For Urothelial Bladder Primaries, stated
high or low grade:SSF 1 – records the grade (010 low, 020
high)Grade (6TH digit) is coded 9Grade Path System and Value = blank
FORDS p. 115 bullet 4, other sections to be clarified in next update
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Grade - ProstateGrade - ProstatePath: adenocarcinoma, Gleason 6Code:
2- moderately differentiatedNot:
9 – unknownSource: FORDS p. 12
WD Gleason 2,3,4MD Gleason 5,6
PD Gleason 7-10
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Grade – GI sitesGrade – GI sitesPath: liver biopsy – moderately
differentiated adenocarcinoma, consistent with colon primary
Code: 9 – grade of colon primary is unknown
FORDS p. 112Code the grade or differentiation from
the pathologic examination of the primary tumor, not from metastatic sites.
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Biopsy vs. SurgeryBiopsy vs. SurgeryIncisional Biopsy
Op Note: breast core needle biopsyCode in Dx/Staging Procedure - 02 biopsy of primary site (a diagnostic procedure)
Excisional BiopsyOp Note: excisional biopsy of breast massCode in Surgery of Primary Site: 22
excisional biopsy (a treatment)
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Surgery Code - Breast Surgery Code - Breast
Op Note: L total Mastectomy, no reconstruction
Code: 41 – Total Mastectomy WITHOUT removal of uninvolved contralateral breast
Not: 40 – Total Mastectomy
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Surgery Code – Mastectomy, Surgery Code – Mastectomy, NOSNOS
MCR Data on Mastectomy Rates
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Surgery Code - Breast Surgery Code - Breast Op Note: R simple mastectomy and
axillary LN dissection
Code: 51 - Modified Radical Mastectomy
Not: 41 - Simple Mastectomy
Source: FORDS p. 270 – simple mastectomy does not include an axillary dissection
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LN Surgery Code – BreastLN Surgery Code – Breast
Op note: Three sentinel lymph nodes removed
Code: 2 – Sentinel lymph node biopsy
Not: 4 - 1-3 LN removed
Source: FORDS p. 225
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LN Surgery Code - BreastLN Surgery Code - BreastOp Note: 5/1/10 - 2 sentinel lymph nodes removed,
pos5/8/10 – axillary LN dissection, 2/5 LN pos
Code: 7 – SLN and code 5, at different times
Not: 5 – four or more regional LN removed
Source: FORDS p. 225
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Surgery Code and DateSurgery Code and DateOp Notes:4/5/10 Lumpectomy5/7/10 Simple Mastectomy
Code:Rx Date Surgery (First) & First Course
= 4/5/10Rx Summ Surgical Procedure of
Primary Site = 41 Simple Mastectomy (see FORDS – code most invasive procedure)
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Surgery Code and DateSurgery Code and Date
Op Notes:4/5/10 Excisional biopsy5/7/10 Re-excision to clear margins
Code:Rx Summ Surgery of Primary Site – 23 – Re-excision
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Surgery Code - Colon Surgery Code - Colon
Colonoscopy Report: polypectomy performed
Code: 28 - polypectomy, endoscopic
Not: 26 – polypectomy, NOS
Source: FORDS p. 255
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Surgery Code – Rectal Surgery Code – Rectal Op Note: polypectomy via
electrocautery snare
Code: 22 - polypectomy, electrocautery
Not: 20 – local excision, or 26 – polypectomy (note: the highest code is not the most detailed)
Source: FORDS p. 259
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Surgery Code - Prostate Surgery Code - Prostate H&P: TURP recommended for BPH
(benign prostatic hyperplasiaPath: incidental finding of prostate
adenocarinoma in 5% of resected tissue
Code: 22 – TURP – cancer is incidental finding during surgery for benign disease
Not: 21 – TURP, NOSSource: FORDS p. 278
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Surgery Code - LymphomaSurgery Code - Lymphoma
CT scan – single suspicious supraclavicular node noted
Op Note/Path – excised node contains lymphoma
Code Surgery Primary Site - 25 Less than a full chain, includes excisional bx single LN
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Date of First Course Date of First Course TherapyTherapyWhen there is a decision not to treat,
Missouri follows the CoC rules.
Code: the date the decision was made: 8/8/2010
Not blank, which is used only for autopsy only cases
Source: FORDS p. 211