Electronic Reporting for Urology Physician Practices
Instructions and Reporting RequirementsModule 2Electronic
ReportingForFacilitiesMarch 2014
North Carolina Central Cancer Registry
State Center for Health StatisticsDivision of Public
HealthDepartment of Health and Human Services1908 Mail Service
CenterRaleigh, NC
27699-1908http://www.schs.state.nc.us/units/ccr/
North Carolina Central Cancer Registry
Hello,
This is Ashanti Scott-Prince again and I will be your trainer.
You are now entering training module two which will review Part II:
Reporting Requirements of the Electronic Reporting for Facilities
training manual.
As before, this training session was produced by the North
Carolina Central Cancer Registry (NCCCR) to guide you on how to use
the New Case Abstract form for facilities.
1Part II: Reporting Requirements
As noted in Module 1, the North Carolina Central Cancer Registry
(NCCCR) collects, processes, and analyzes data on all cancer cases
diagnosed among North Carolina residents. This is primarily a
cancer surveillance activity, monitoring the incidence of cancer
among the various populations of the state.All health care
providers are required by law to report cases to the NCCCR (as in
nearly all other states). Traditional data collection for central
cancer registries has been primarily from hospitals. As medical
advances have occurred, diagnosis and treatment of certain cancers
has moved from the acute care setting to being fully cared for
within the physician/clinic office and, therefore, never received
and counted. Examples include melanoma of the skin; prostate
cancer; and many hematopoietic malignancies like chronic
lymphocytic leukemia, polycythemia vera and myelodysplastic
syndrome. The NCCCR supplements hospital data with reports from
physician/clinic offices who diagnose cases that are not seen in a
hospital. In addition, death certificates and pathology laboratory
reports are used to help identify cases that are missed in this
routine reporting by hospitals and physician/clinic offices. Any
duplicate reports are consolidated in the data editing process. The
purpose of this concerted effort is to alleviate under-reporting or
a delay in reporting which can adversely affect incidence rates and
research from incomplete data collection.
Please ensure you have your Electronic Reporting for facilities
training manual open to follow along or printed out to use for note
taking.
2Part II: Reporting RequirementsSection II.1: Reporting
ProceduresMUST use the New Case Abstract Form to report an eligible
case of cancer One for each independent primary tumorA separate
report must be completed and submitted for each primary
tumor.Example: If a patient is diagnosed with bladder cancer and a
separate kidney cancer, a separate report must be submitted for
each diagnosis.Accuracy and thorough, complete reporting is
necessaryPlease complete the form as ACCURATELY and COMPLETELY as
possible.Once the report is free of errors and is successfully
submitted, it is considered as having been reported to the
NCCCRCopies of the medical record, paper version of the reporting
form, or lists of reported patients are not required to be sent to
the NCCCR.
The topic for this module, PART II: REPORTING REQUIREMENTS, is
divided into three sections. Section II.1: Reporting
ProceduresSection II.2: Cases Required to be Reported and Section
II.3: Cases NOT Required to be Reported
We will begin now with Section II.1: Reporting Procedures.
To report an eligible case of cancer, the on-line Eureka New
Case Abstract form must be used. A separate report must be
completed and submitted for each independent primary tumor. For
example, if a patient is diagnosed with bladder cancer and a
separate kidney cancer, a separate report must be submitted for
each diagnosis.Accuracy and thorough, complete reporting is
necessary! Please complete the electronic reporting form as
ACCURATELY and COMPLETELY as possible. Once the report is free of
errors and is successfully submitted, it is considered as having
been reported to the NCCCR. Copies of the medical record, paper
version of the reporting form, or faxed lists of reported patients
are not required to be sent to the NCCCR.
We will review HOW to report using the form in subsequent
Sections. The main point to take away from this section is that you
understand how important it is to have accurate and complete data.
The screen has built-in programming which will help to identify
when there are errors or discrepancies in the data entered.
3Part II: Reporting RequirementsSection II.1: Reporting
Procedures - continuedBrief summary of steps required to report
cases. Each step will be described in detail throughout the
document and this training.Obtain a Eureka account for each
facility.Obtain a Eureka user id and password for each staff person
designated to report cases. Consider limiting this to two or three
staff per facility.Each user MUST have a personal user id and
password.Identify potential cases using the suggested casefinding
procedures.Determine if the case should be reported using the case
eligibility criteria.Access the electronic New Case Abstract form
to enter and submit cases using the required data-entry
specifications.Track cases that have been reported to avoid
duplicate reporting.
Continuing with PART II: REPORTING REQUIREMENTS in the
Electronic Reporting for Facilities training manual, Section II.1:
Reporting Procedures.The following provides a brief summary of the
steps required to report cases. Each of these steps will be
described in detail throughout the document and this training. If
you follow this order, ensuring you have completed each step
required, you will be on your way to submitting cases as
required.Obtain a Eureka account for each facility.Obtain a Eureka
user id and password for each staff person designated to report
cases. Consider limiting this to two or three staff per facility.
Each user MUST have a personal user id and password.Identify
potential cases using the suggested casefinding
procedures.Determine if the case should be reported using the case
eligibility criteria. Access the electronic reporting form to enter
and submit cases using the required data-entry specifications.
Track cases that have been reported to avoid duplicate
reporting.These steps will be more thoroughly explained in later
segments of this training.4Part II: Reporting RequirementsSection
II.2: Cases Required to be ReportedAll health care facilities and
providers are required to report:Eligible cancer cases and
Non-malignant Central Nervous System (CNS) tumors, including:Brain,
meninges and other CNS that are screened, diagnosed, treated or
seen with evidence of cancer.Clinically diagnosed cases (not
histologically confirmed)
We now move to Section II.2: Cases Required to be Reported of
the Electronic Reporting for Facilities training manual.
One of the critical pieces of case reporting is to know what is
reportable. The overall topic for this and the next few slides is
reporting is required for all reportable diagnoses that meet
specific criteria.
The next few slides provide a brief overview of what is or is
not reportable. Rest assured we will provide more detail to assist
you in later slides.
In North Carolina all health care facilities and providers are
required to report:Eligible cancer cases
Non-malignant Central Nervous System (CNS) tumors
includingBrain, meninges and other CNS that are screened,
diagnosed, treated, or seen with evidence of cancer
and
Clinically diagnosed cases (not histologically confirmed)
5Part II: Reporting RequirementsSection II.2: Cases Required to
be ReportedAll health care facilities and providers are required to
report:Clinically diagnosed cases (not histologically
confirmed)Consider the following as
equivalent:TumorMassLesionNeoplasm
Continuing with Section II.2: Cases Required to be Reported of
the Electronic Reporting for Facilities training manual.An addition
to reporting eligible cancer cases and non-malignant Central
Nervous System (CNS) tumors (including brain, meninges, and other
CNS) that are screened, diagnosed, treated, or seen with evidence
of cancer, and clinically diagnosed cases (not histologically
confirmed) must also be reported.
Consider the following terms as equivalent: tumor, mass, lesion,
neoplasm.
Therefore, reporting is required for all cancer diagnosed
cases.6Part II: Reporting RequirementsSection II.2: Cases Required
to be Reported - continuedReporting is required for all diagnoses
that meet the following criteria - continued:Cell Type /
Histology:Any tumor/condition described as:MalignantCancerCarcinoma
(adenocarcinoma, transitional cell carcinoma,
etc.)SarcomaMelanomaLymphomaLeukemiaIntraepithelial Neoplasia,
Grade III (8077/2) of the following sites:Anal (AIN III)Vaginal
(VAIN III)Vulvar (VIN III)
Reporting is required for all cancer diagnoses that meet the
following criteria listed on this and the following slides. This
page begins to review the Cell Type or Histology.
You can consider these as reportable if the Cell Type or
Histology is described as:
Any tumor/condition described as:MalignantCancerCarcinoma
(adenocarcinoma, transitional cell carcinoma,
etc.)SarcomaMelanomaLymphomaLeukemiaIntraepithelial Neoplasia,
Grade III (8077/2) of the following sites:Anal [AIN III]Vaginal
[VAIN III]Vulvar [VIN III]
7Part II: Reporting RequirementsSection II.2: Cases Required to
be Reported - continuedReporting is required for all diagnoses that
meet the following criteria - continued:Cell Type /
Histology:Squamous cell carcinoma originating in a mucoepidermoid
site:
Lip C00.1 C00.9Vagina C52.9Anus C21.0Prepuce C60.0Labia C51.0
C51.1Penis C60.1 C60.9Clitoris C51.2Scrotum C63.2Vulva C51.9
This slide continues a review of aspects of CRITERIA for all
cancer diagnoses you should be reporting for, specifically Cell
Type / Histology.
You can consider these as reportable if the Cell Type or
Histology is described as:
Squamous cell carcinoma originating in a mucoepidermoid site:Lip
C00.1 C00.9Anus C21.0Labia C51.0Clitoris C51.2Vulva C51.9Vagina
C52.9 Prepuce C60.0Penis C60.1 - C60.9 Scrotum C63.2
8Part II: Reporting RequirementsSection II.2: Cases Required to
be Reported - continuedReporting is required for all diagnoses that
meet the following criteria - continued:
Behavior Code:Tumors that are invasive (ICD-O-3 Behavior code of
/3)Tumors that are in-situ (ICD-O Behavior code of /2)If the usual
behavior code is /0 (benign) or /1 (uncertain) but a pathologist
designates the tumor as in-situ or malignant, these cases are
reportable.
Another important aspect of reporting is the Behavior Code. The
Behavior Code is defined by the International Classification of
Disease for Oncology, 3rd Edition (ICD-O-3). If the diagnosis has
been given one of these Behavior Codes, consider the case
reportable. The diagram on this slide indicates where the Behavior
Code can be found. We will talk in more detail about this on the
next slide. However, use these as an overall guide:
Tumors that are invasive will have an ICD-O-3 Behavior code of
/3Tumors that are in-situ will have the ICD-O-3 Behavior code of
/2If the usual behavior code is /0 (benign) or /1 (uncertain) but a
pathologist designates the tumor as in situ or malignant, these
cases are reportable.
9Part II: Reporting RequirementsSection II.2: Cases Required to
be Reported - continuedReporting is required for all diagnoses that
meet the following criteria - continued:Behavior Code -
continued:International Classification of Disease for Oncology, 3rd
Edition (ICD-O-3) Dual classification used principally in cancer
registries with coding systems for bothTopography (site)
andMorphology(histology)Describes characteristics of the tumor
itself, including its cell type and biologic activityMorphology
axis on the diagram provides five-digit codes ranging from M-8000/0
to M-9992/3.First four digits indicate the specific histological
termFifth digit after the slash (/) is the behavior code Indicated
whether a tumor is malignant, benign, in situ, or uncertain (if
benign or malignant)Separate one-digit code is provided for
histologic grading (differentiation).
We continue with the topic of Reporting is required for all
cancer diagnoses that meet the following criteria.
Specifically, we continue with the Behavior Code:
The Behavior Code is defined by The International Classification
of Disease for Oncology, 3rd Edition (ICD-O-3) which is a dual
classification used primarily in cancer registries with coding
systems for both topography (site) and morphology (histology).
You can see by the diagram that the royal blue color shows the
cell type or morphology code. The morphology code describes the
characteristics of the tumor itself, including its cell type and
biologic activity. The morphology axis provides five-digit codes
ranging from M-8000/0 to M-9992/3. The first four digits indicate
the specific histological term.
The bright yellow section of the diagram shows the fifth digit
after the slash (/) which is the behavior code, which indicates
whether a tumor is malignant, benign, in situ, or uncertain (if
benign or malignant).
The aqua section of the diagram shows a separate one-digit code
that is also provided for histologic grading (differentiation).
10Part II: Reporting RequirementsSection II.2: Cases Required to
be Reported continuedReporting is required for all diagnoses that
meet the following criteria - continued:Diagnostic Confirmation
(Method used to confirm the diagnosis)Histologically confirmed
casesTissue examined and confirmed to be cancerCytologically
confirmed casesFluid examined and confirmed to be cancer
Continuing with Section II.2: Cases Required to be Reported we
move to the topic of Diagnostic Confirmation or Method used to
confirm the diagnosis is discussed.
This is a continuation of the topic: Reporting is required for
all cancer diagnoses that meet the following criteria with one more
aspect of the criteria. Diagnostic Confirmation or the Method used
to confirm the diagnosis is important to ensure validity of the
diagnosis.
Most diagnosed cases have been confirmed using at least one of
the following:Histologically confirmed cases are cases where tissue
was examined and confirmed to be cancer.Cytologically confirmed
cases are cases where fluid was examined and confirmed to be
cancer.And, Clinically diagnosed cases which are cases confirmed by
means other than microscopic examination such as positive radiology
or laboratory results. (which will be reviewed on the next
slide)
11Part II: Reporting RequirementsSection II.2: Cases Required to
be Reported continuedReporting is required for all diagnoses that
meet the following criteria - continued:Diagnostic Confirmation
(Method used to confirm the diagnosis)Clinically diagnosed
casesConfirmed by means other than microscopic examination Such as
positive radiology or laboratory resultsA diagnosis must be
reported even if it has not been microscopically confirmed.If the
physician states the patient has cancer, the case is reportable If
the diagnosis could not be definitively confirmed but is being
treated as a malignancy, the case is reportable.
Continuing with Diagnostic Confirmation or the Method used to
confirm the diagnosis is important to ensure validity of the
diagnosis. Most diagnosed cases have been confirmed using at least
one of the following:
In the last slide we reviewed:Histologically confirmed cases are
cases where tissue was examined and confirmed to be
cancer.Cytologically confirmed cases are cases where fluid was
examined and confirmed to be cancer.
Here we introduce the third diagnostic confirmation: Clinically
diagnosed cases which are cases confirmed by means other than
microscopic examination such as positive radiology or laboratory
results. It is important to note that a diagnosis must be reported
even if it has not been microscopically confirmed.If the physician
states the patient has cancer, the case is reportable.If the
diagnosis could not be definitively confirmed but is being treated
as a malignancy, the case is reportable.
12Part II: Reporting RequirementsSection II.3: Cases NOT
Required to be Reported The following types of cases are not
required to be reported:Prostate Intraepithelial Neoplasia, Grade
III (PIN III) 8148/2Cervix Intraepithelial Neoplasia, Grade III
(CIN III) 8077/2Carcinoma in situ (CIS) of the cervix only. All
other in situ cases are reportable.Basal and Squamous cell cancers
(histology codes: 8000-8110) of the skin only (site code: C44._
only) are not reportableBasal cell and squamous cell cancers of any
other site are reportableSkin of labia (C51.0), vulva (C51.9),
penis (C60.9) and scrotum (C63.2) are reportablePatients seen only
in consultation to provide a second opinion to confirm a diagnosis
or a treatment plan.Patients in remission (there is no evidence of
active disease) and not receiving prophylactic or adjuvant
therapy.
We now move to Section II.3: Cases NOT Required to be Reported
of the Electronic Reporting for Facilities training manual.This is
a full slide but we thought it would be helpful for you to see all
of these exceptions in one location.
The following types of cases listed on this slide are not
required to be reported: Prostate Intraepithelial Neoplasia, Grade
III (PIN III) 8148/2Cervix Intraepithelial Neoplasia, Grade III
(CIN III) 8077/2Carcinoma in situ (CIS) of the cervix only. All
other in situ cases are reportable.Basal and Squamous cell cancers
(histology codes: 8000-8110) of the skin only (site code: C44._
only) are not reportable. Note: Basal cell and squamous cell
cancers of any other site are reportable. Skin of labia (C51.0),
vulva (C51.9), penis (C60.9) and scrotum (C63.2) are
reportable.Patients seen only in consultation to provide a second
opinion to confirm a diagnosis or a treatment plan.Patients in
remission (there is no evidence of active disease) and not
receiving prophylactic or adjuvant therapy.
.
13Part II: Reporting RequirementsSection II.3:The NCCCR
understands the scope of work required to meet these requirements
for facilities. Therefore, physician offices are not being asked to
report cases that meet either of the following two criteria: It is
documented that the patient was previously seen as an inpatient or
outpatient at a hospital or cancer treatment facility in North
Carolina for the diagnosis or treatment for this tumor. It is
documented that the patient later went to a hospital or cancer
treatment facility in North Carolina and it is known that the other
facility provided management for the diagnosis or treatment of this
tumor.
Continuing with Section II.3: Cases NOT Required to be
Reported.The NCCCR understands the scope of work required to meet
these requirements for physician offices. Therefore, physician
offices are not being asked to report cases that meet either of the
following two criteria:
It is documented that the patient was previously seen as an
inpatient or outpatient at a hospital with a cancer program
accredited by the Commission on Cancer or cancer treatment facility
in North Carolina for the diagnosis or treatment for this
tumor.
It is documented that the patient later went to a hospital with
a cancer program accredited by the Commission on Cancer or cancer
treatment facility in North Carolina and it is known that the other
facility provided management for the diagnosis or treatment of this
tumor.
14Part II: Reporting RequirementsSection II.3
continued:Conditions of this situation:The other facilityMust be in
North CarolinaCannot be another physicians office or treatment
center not associated with a North Carolina facilityMust have
provided cancer directed management of this tumorIf patient seen at
another facility other than this tumor, or for reasons other than
the direct management of this tumor, the case must be reported by
the physician.If in doubt if a diagnosis meets reportability
criteriaSubmit a reportReduces the need to report these as missed
cases later
Continuing with Section II.3: Cases NOT Required to be Reported
of the Electronic Reporting for Facilities training manual.In this
situation, the other facility must be in North Carolina and cannot
be another physicians office or treatment center not associated
with a N.C. facility. Also, the other facility must have provided
cancer-directed management of this tumor. If the patient was seen
at another facility for a condition other than this tumor, or for
reasons other than the direct management of this tumor, the case
must be reported by the physician. If in doubt about whether the
diagnosis meets the reportability criteria for physician offices,
please submit a report. This will reduce the need to report these
as a missed case at a later time.
15Part IIReporting Requirements Completed
This completes the training module for Part II: Reporting
Requirements. Please close when you are ready and move to the next
link to access the training module for Part III: Casefinding.
Thank you!16