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Coding Surgery in 2001 and SEER Summary Stage 2000

Coding Surgery in 2001 and SEER Summary Stage 2000. FCDS 2001 Educational Telephone Conference Series June 20, 2001 Mary O’Leary, RHIT, CTR Joy Houlahan, CTR. References. During this presentation you will need: 2001 FCDS Data Acquisition Manual

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Coding Surgery in 2001 and SEER Summary Stage 2000

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  1. Coding Surgery in 2001andSEER Summary Stage 2000 FCDS 2001 Educational Telephone Conference Series June 20, 2001 Mary O’Leary, RHIT, CTR Joy Houlahan, CTR

  2. References During this presentation you will need: • 2001 FCDS Data Acquisition Manual • SEER Summary Staging Manual 2000 Codes and Coding Instructions • All handouts made available on the FCDS website in either Word or .pdf format

  3. References • 2001 FCDS Data Acquisition Manual, April 2001 • SEER Program Code Manual 3rd Edition, 1998 • Standards of the Commission on Cancer, Volume II: Registry Operations and Data Standards (ROADS), January 1998 revision

  4. NOTE:The general instructions and codes for all surgery fields collected by FCDS for 2001 cases, are identical for SEER, CoC/ACoS and FCDS

  5. FCDS History of Coding Surgery • Surgery - Yes/No • Until 1995 for FCDS • Not Site-Specific • Surgery - One field, two-digit code • Until 2000 for FCDS • Site-Specific Code Sets • Represented all types of surgery to remove cancer - localized surgery, regional or distant

  6. FCDS History of Coding Surgery • Surgery - Five fields, lots of codes • 2001 Admissions for FCDS • Site-Specific Code Sets for each data item • One field for surgery to primary site • One field for surgery to lymph nodes • One field for surgery to regional or distant sites • One field to document # lymph nodes removed • One field to explain why no surgery done

  7. Surgery of Primary Site • Record surgery of primary site, ONLY • Use the Site-specific Surgery Codes found in the 2001 FCDS DAM, Appendix H • Code first course treatment, ONLY • Surgery to remove regional tissue/organs is not coded in this field unless they are part of an “en bloc” resection along with the primary site.

  8. Surgery of Primary Site • If the patient has multiple surgeries of the primary site, code the most invasive and definitive surgery (highest code) • If multiple cancers (primaries) are excised during the same surgical procedure, refer to each site-specific surgery coding scheme for each primary site (keep them separate)

  9. Surgery of Primary Site - Format 00 No Surgery of Primary Site 10 Minimal Procedure, NOS 11 Without detail 12 With detail 20 More extensive procedure, NOS 21 Without detail 22 etc….

  10. Scope of Regional Lymph Node Surgery • Always refer to the site-specific codes for this data item, 2001 FCDS DAM, Appdx H • Code first course treatment, ONLY • This data item refers to the surgical procedure and does not imply that any lymph nodes were found during the pathologic examination of the specimen removed

  11. Scope of Regional Lymph Node Surgery • Record regional lymph nodes only • refer to the list of site-specific regional nodes found in the 2001 FCDS DAM, Appdx H • Any other nodes are distant, and should be coded in the data field “Surgery of Other Regional Site(s), Distant Site(s) or Distant Lymph Node(s)”.

  12. Regional Lymph Nodes Examined/Removed • Record the number of regional lymph nodes examined during the most definitive surgical procedure, • Code first course treatment, ONLY • Do not add numbers of nodes removed at different surgical events.

  13. Regional Lymph Nodes Examined/Removed • Important Note: This field does not replace or duplicate the field documenting the pathologic review of “Regional Nodes Examined” in the Tumor Information and Staging section of the abstract. • Do not copy values from one field to the other.

  14. Surg of Other Regional Site(s)/Distant Site(s)/Distant Nodes • Removal of tissue(s) or organ(s) other than the primary tumor. • The tissue or organ is not removed with the primary tumor or organ of origin (not en bloc resection). • Do not code incidental removal of tissue. This is defined as tissue removed for reasons other than malignancy.

  15. Reason for No Surgery • Enter a code for the reason that no surgery was performed, from the list of codes on page II-70 in the FCDS DAM 2001. • If a site-specific surgery is coded then the “Reason for No Surgery” must be coded “0”, indicating that surgery was performed

  16. Example...

  17. Surgery: Lung Cancer - lobectomy with excision of 4 hilar lymph nodes • Formerly, code 40 summarized this surgery in one (two-character) field • New codes describe the same surgery using 4 different fields, plus a code for “Reason For No Surgery”

  18. Surgery: Lung Cancer - lobectomy with excision of 4 hilar lymph nodes • Surgery of Primary Site • Code 31 - Lobectomy • This field only describes surgery for the primary site with no information about lymph node dissection or regional/distant sites

  19. Surgery: Lung Cancer - lobectomy with excision of 4 hilar lymph nodes • Scope of Regional Lymph Node Surgery • Code 2 - Ipsilateral Hilar Nodes • When lymph node dissection is part of the surgery, determine which nodes were excised and use the highest code that accurately describes them

  20. Surgery: Lung Cancer - lobectomy with excision of 4 hilar lymph nodes • Number of Regional Lymph Nodes Examined/Removed • Code 04 - 4 nodes removed • Record the number of regional lymph nodes removed during this surgical procedure only. Do not add number of nodes removed at different surgical events.

  21. Surgery: Lung Cancer - lobectomy with excision of 4 hilar lymph nodes • Surgery of Other Regional Site(s), Distant Site(s) or Distant Lymph Nodes. • Code 0 - None • There was no surgery performed on other regional or distant site(s)

  22. Surgery: Lung Cancer - lobectomy with excision of 4 hilar lymph nodes • Reason for No Surgery • Code 0 - surgery was performed • There was a surgical procedure which removed cancerous tissue

  23. Confused?Surgery Code Clarification Table A Surgery Code Clarification Table is available on the Commission on Cancer website (http://www.facs.org). This table addresses changes in the name and/or the meaning of current and revised standards (March 2000).

  24. Important Websites for Info • FCDS - http://www.fcds.med.miami.edu • SEER - http://www-seer.ims.nci.nih.gov • CoC/ACoS - http://www.facs.org (click on cancer department) • CDC - http://www.cdc.gov/cancer/npcr • NAACCR - http://www.naaccr.org

  25. Time to exercise! • We will pause in this slide presentation to do the Surgery Code exercises included in the handouts.

  26. SEER Summary Stage 2000

  27. SEER Summary Stage 2000 • Must be used for all cases diagnosed on or after January 1, 2001 • Must also be accompanied by FCDS Stage At First Contact 2000 for all cases diagnosed on or after January 1, 2001

  28. SEER Summary Stage 2000 The same staging manual must be used to code both SEER Summary Stage at Diagnosis and FCDS Stage at First Contact

  29. SEER Summary Stage 2000 This applies to all cases diagnosed 2001 and after - Use SEER Summary Stage 2000 You still must use SEER Summary Stage 1977 for all cases diagnosed prior to 2001

  30. SEER Summary Stage 2000 • Major differences between SS2000 and the 1997 Summary Staging Guide • Each anatomic site in ICD-O-3 now has its own staging scheme

  31. SEER Summary Stage 2000 • Certain specific histology-defined sites now have their own staging scheme (such as Kaposi Sarcoma) • Colon now has one staging scheme for all subsites (sigmoid, ascending, etc.)

  32. SEER Summary Stage 2000 • More complete documentation of regional sites and regional lymph nodes • Additional anatomic drawings • Notations at the end of each staging scheme describing changes in staging over time

  33. SEER Summary Stage 2000 • Everyone…PLEASE read the expanded Introduction Section - it is full of important information for both the new and the experienced registrar…this means YOU ! • Turn to page 4 to review example of importance of terminology, anatomy & physiology throughout the manual!

  34. SEER Summary Stage 2000 • Instructions for using the SEER Summary Staging Manual - 2000 • Definitions explaining each staging category (In situ, Localized, etc.) • General Guidelines for Summary Staging

  35. SEER Summary Stage 2000 • How to Assign Summary Stage: concise and basic guidelines (page 12) • Explanation of abbreviations and symbols used in this manual • Definitions, including some medical terminology • Ambiguous terminology relating to staging

  36. SEER Summary Stage 2000 • Refer to Handout - Respiratory Tract • Respiratory Tract • Trachea • Bronchus and Lung • Drawings • Staging Criteria • Notes & Footnotes - IMPORTANT !!!

  37. SEER Summary Stage 2000 • Primary tumor in lung with extension to adjacent rib: considered regional in Historic Stage, now coded to distant stage • Separate tumor nodule(s) in different lobe of same lung: considered localized in Historic Stage and 1977 Summary Staging Guide, now coded to distant stage

  38. SEER Summary Stage 2000 • QUESTIONS ????????? • Please contact FCDS and we will get you the answers … so we can include them in our Monthly Memo and/or Newsletter • THANKS !!!!!

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