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Demographics & Patient Information

Demographics & Patient Information. Texas Cancer Registry. Objectives. By the end of this training, you should be able to discuss coding related to: Reporting Facility Number Type of Reporting Source Date of Admission/First Contact Accession Number Medical Record Number Class of Case

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Demographics & Patient Information

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  1. Demographics & Patient Information Texas Cancer Registry

  2. Objectives By the end of this training, you should be able to discuss coding related to: • Reporting Facility Number • Type of Reporting Source • Date of Admission/First Contact • Accession Number • Medical Record Number • Class of Case • Patient Information • Physician Follow-Up • Sequence Numbers • Primary Payer • Tobacco Use Texas Cancer Registry | Demographics and Patient Information

  3. Reporting Facility Number • Identifies the facility reporting the case • Monitors data submissions • Ensures accuracy of data • Identifies areas for special studies • 3 digit number assigned by TCR with 7 leading zeros Texas Cancer Registry | Demographics and Patient Information

  4. Type of Reporting Source • Identifies the best source documents used to abstract the cancer case • Inpatient or outpatient charts • Physician’s offices • Patients diagnosed at autopsy • Path reports only • Death certificates Texas Cancer Registry | Demographics and Patient Information

  5. Type of Reporting Source Texas Cancer Registry | Demographics and Patient Information

  6. Type of Reporting SourcePop Quiz Scenario: A patient is admitted to your facility and expires before any treatment is rendered. An autopsy is performed and cancer is found in the lung. What is the Type of Reporting Source Code? Texas Cancer Registry | Demographics and Patient Information

  7. Type of Reporting SourcePop Quiz Scenario: A patient is admitted to your hospital and is diagnosed with lung cancer. What is the Type of Reporting Source Code? Texas Cancer Registry | Demographics and Patient Information

  8. Type of Reporting SourcePop Quiz Scenario: The only patient record available for a physician office biopsy is the pathology report identified from a freestanding laboratory. What is the Type of Reporting Source Code? Texas Cancer Registry | Demographics and Patient Information

  9. Date of Admission/First Contact • Date of first admission/contact at your facility for diagnosis and/or treatment of cancer or active disease • Punctuation marks not allowed • The format is YYYYMMDD • If never admitted enter date of outpatient, x-ray, lab test, or emergency room visit • Autopsy only enter the date of death • Path only or read only enter date specimen was taken Texas Cancer Registry | Demographics and Patient Information

  10. Date of Admission/First Contact Scenario: A patient is admitted to your hospital on Jan. 31, 2018 with chest pains. On Feb. 2, 2018 a CT scan shows that the patient has a lung mass consistent with malignancy. What is the Date of Admin/First Contact? Texas Cancer Registry | Demographics and Patient Information

  11. Date of Admission/First Contact Scenario: A patient has a biopsy in a staff physician’s office on March 17, 2018. The specimen is sent to your facility’s pathology department that same day and your pathologist reads the specimen as malignant melanoma. The patient enters your facility on March 21, 2018 for a wide re-excision. What is the Date of Admin/First Contact? Texas Cancer Registry | Demographics and Patient Information

  12. Date of Admission/First Contact Scenario: A patient has a lymph node biopsy at a small hospital on May 15, 2018. The specimen is sent to your hospital to be evaluated in your pathology department. The pathologist reports diffuse large B-cell lymphoma. The patient never enters your facility. What is the Date of Admin/First Contact? Texas Cancer Registry | Demographics and Patient Information

  13. Accession Number • Accession number is unique to identify each patient regardless of number of primaries • First 4 digit are year patient is seen at your facility, the last 5 digits represent the order patient entered in registry • 201800001 – patient seen in 2018 and was the first cancer patient abstracted into registry • Do not assign a new registry number to a patient previously reported to the TCR Texas Cancer Registry | Demographics and Patient Information

  14. Medical Record Number • Patient’s medical record number assigned by reporting facility • 11 digit medical record number used to identify the patients first admission with active cancer and/or on cancer treatment • Medical record numbers with less than 11 digits and/or alpha characters accepted • If a medical record number is not available for outpatient or emergency room visits enter Op with 9 0’s Texas Cancer Registry | Demographics and Patient Information

  15. Medical Record Number Texas Cancer Registry | Demographics and Patient Information

  16. Class of Case Class of case identifies the facility’s role in the diagnosis and treatment of the patient’s cancer • Analytic Case -- diagnosis and/or first course of treatment was at reporting facility • Non-Analytic Case -- Diagnosis and first course of treatment was done elsewhere Texas Cancer Registry | Demographics and Patient Information

  17. Class of Cases: Analytical Cases • Codes 00-14 indicate the patient was diagnosed at the facility and should be abstracted within 6 months of diagnosis • Codes 20-22 indicate the patient was diagnosed elsewhere but had first course of treatment at your facility. It should be abstracted within 6 months of first contact with reporting facility Texas Cancer Registry | Demographics and Patient Information

  18. Class of Cases:Non-Analytical Cases For Codes 30-38: • Patient appears in person at reporting facility but the initial diagnosis and first course of treatment was done elsewhere • Patient received treatment prior to reference date • Abstracting should be completed within 6 months of first contact with reporting facility • Be sure “history of” is really “history of” and not reportable Texas Cancer Registry | Demographics and Patient Information

  19. Class of Cases:Non-Analytical Cases For Codes 40-48, the patient did not appear in person at reporting facility, including the following circumstances: • Patient was treated by a staff physician • Patient received care from an agency and the reporting facility reports for that agency. (Example – hospital abstracts cases from an independent radiation facility.) • Case is from pathology report or death certificate only Codes 49 and 99 are only used by TCR staff Texas Cancer Registry | Demographics and Patient Information

  20. Class of Case Scenario: A patient is admitted to your facility for dizziness and falling. The patient receives clinical workup which includes CT and MRI of the brain. Results are positive for brain metastasis. The patient goes to another facility for treatment of lung cancer and brain metastasis. What is the Class of Case code? Texas Cancer Registry | Demographics and Patient Information

  21. Class of Case Scenario: A patient is diagnosed with colon cancer at your facility and undergoes a hemicolectomy. She then receives chemotherapy at an outside clinic. What is the Class of Case Code? Texas Cancer Registry | Demographics and Patient Information

  22. Class of Case Scenario: Patient was diagnosed and treated for primary bladder cancer prior to admission to your facility. Your facility admits patient for cystectomy for recurrent bladder cancer. After treatment failure, the patient was admitted to the facility for supported care. What is the Class of Case Code? Texas Cancer Registry | Demographics and Patient Information

  23. Patient Name Fields • Last Name • Cannot be left blank • Spaces, hyphens, apostrophes and punctuation marks are allowed • Examples: O’HARA, DE LEON, SMITH–JONES • First Name • Cannot be left blank • Enter ‘Unknown’ if first name can’t be determine • Middle Name – Can enter the name, an initial or leave it blank • Maiden Name – Can enter the name or leave it blank • Alias name • Can enter name or can be blank • Examples: Katherine Smith’s alias is Kate; record SMITH KATE Texas Cancer Registry | Demographics and Patient Information

  24. Patient Address Fields • Enter the patient’s address at the time of diagnosis. This helps identify potential cancer clusters. • Use a physical address instead of a PO Box. • Use proper US Post Office abbreviations. Visit the USPS website for postal addressing standards, including street suffix abbreviations. Texas Cancer Registry | Demographics and Patient Information

  25. Patient Address Fields • For the address, enter: • Street Address, City and State • ZIP Code • FIPS code • Country • If patient has multiple addresses, code the address where the patient spends the majority of time Texas Cancer Registry | Demographics and Patient Information

  26. Patient Address Fields • Address at Dx – Supplemental • Allows you to include the name of a nursing home or apartment complex • If unknown, leave blank • Do not use this field to enter additional street address information (e.g., apartment, suite or trailer number) Texas Cancer Registry | Demographics and Patient Information

  27. Social Security Numberand Date of Birth • Social Security Number (SSN) • Enter SSN with no punctuation • Do not enter a spouse’s SSN or the Medicare number • If SSN is unknown, enter all 9’s • If only the last 4 of SSN available, enter all 7s for the first 5 digits and the last 4 of the SSN (777771234) • Date of Birth (DOB) • Enter DOB without punctuation marks in the new date format • TCR requires at least year • DOB helps TCR match records and calculate age at diagnosis Texas Cancer Registry | Demographics and Patient Information

  28. Birthplace State and Country • Record the patient’s state of birth, if available • Use the USPS two-character state abbreviation • If unknown, enter ZZ • Record the patient’s country of birth, if available • Use the USPS three-character country abbreviation • If unknown, enter ZZU Texas Cancer Registry | Demographics and Patient Information

  29. Patient Race • Race is entered as a two-digit code • Five fields are available to allow the coding of multiple races • Priority source • Patient statement • Medical record documentation • Death certificate • Assign same codes for all tumors Texas Cancer Registry | Demographics and Patient Information

  30. Patient Race • If patient is one race, code the first field accordingly and enter 88 (no additional races) in the remaining fields • If race is unknown, enter 99 (unknown) in all five fields • A unique race code (other than 88 or 99) can only be recorded once in race fields 1-5 • Document specified race codes in “Other Pertinent Information” text field • Certain codes take priority over other codes Texas Cancer Registry | Demographics and Patient Information

  31. Patient Race • Code as 01 (white) • Race described as White or Caucasian • Only have statement that patient is Hispanic or Latino, NOS • Codes 02-32, 96-98 take priority over Code 01 • Code 07 (Hawaiian) takes priority • Specific race takes priority over non-specific race code • Do not use codes 96, 97 or 98 for multi-racial Texas Cancer Registry | Demographics and Patient Information

  32. Patient Spanish/Hispanic Origin This code identifies if patient is of Hispanic origin • Use code 0 if non-Hispanic • Use codes 1-5 & 8 if Hispanic ethnicity is known • Use code 6 if patient is known to be Hispanic, NOS • Code 9 if unknown whether patient is Hispanic Texas Cancer Registry | Demographics and Patient Information

  33. Patient Sex Code Definitions • Trans-sexual – surgically altered gender • Transgendered – a person who identifies with or expresses a gender identity that differs from the one which corresponds to the person’s sex at birth • Hermaphrodite – a person having both male and female reproductive organs • Intersexed – a person with certain sex chromosome abnormalities Texas Cancer Registry | Demographics and Patient Information

  34. Patient Sex Codes Always verify sex with the primary site. For example: • If primary site is ovary, patient sex is 2 or 6 • If primary site is prostate, patient sex is 1 or 5 Texas Cancer Registry | Demographics and Patient Information

  35. Patient Industry and Occupation Industry and occupation information is used to identify work-related health hazards • Usual Industry Text Field • Enter the patient’s usual industry or kind of business • Used to identify work-related health hazards • Examples: Automobile manufacturing, Copper mining • Usual Occupation Text Field • Enter the patient’s usual job or work, being as specific as possible • Examples: Residential brick layer (instead of laborer), chemical engineer (instead of engineer) Texas Cancer Registry | Demographics and Patient Information

  36. Text Field for Other Pertinent Information Use this field to include additional information on patient that you couldn’t adequately address elsewhere Examples: • Explain lack of information in the medical record • Text overflow from other text boxes • Documentation of race and sex • Cause of death • Names of following physicians • Anything requiring clarification Texas Cancer Registry | Demographics and Patient Information

  37. Physician Follow-Up • Identifies the physician responsible for the patient’s medical care • The TCR requires the State License Number for the follow-up physician. You can locate this number on the Texas Medical Board website: http://www.tmb.state.tx.us/page/look-up-a-license • If license number is unknown, code with all 9’s and document in the other pertinent information text field Texas Cancer Registry | Demographics and Patient Information

  38. Sequence Numbers • Sequence number indicates the number of all reportable neoplasms, both malignant & non-malignant, over the patient’s lifetime regardless of when or where the cancer was diagnosed. • Metastatic disease is not counted. • Codes 00-59 & 99 indicate reportable cases of malignant or in situ behavior. These are the morphology codes with the fifth digit behavior codes 2 & 3. • Codes 60-88 indicate reportable non-malignant neoplasms of benign or borderline behavior. These are the morphology codes with the fifth digit behavior code 0 & 1. Texas Cancer Registry | Demographics and Patient Information

  39. Sequence Numbers Sequence number codes 00-59 and 99 indicate reportable cases of malignant or in situ behavior. • Total number of malignant tumors in a patient’s lifetime (not facility specific) • Reportable cases of malignant or in situ behavior • Behavior code 2 or 3 • Use 99 as the sequence number if the patient had more than one (or several) malignant tumors and there is no additional information as to how many or what the primary sites are. Texas Cancer Registry | Demographics and Patient Information

  40. Sequence Numbers Sequence number codes 60-87 and 88 indicate cases of non-malignant tumors. • Total number of non-malignant tumors (behavior code 0 or 1) in a patient’s lifetime (not facility specific) • This includes benign and borderline CNS cases. • Use 88 as the sequence number if the patient had more than one (or several) non-malignant tumors and there is no number documented. Texas Cancer Registry | Demographics and Patient Information

  41. Sequence NumbersPop Quiz A person was diagnosed with signet ring cell carcinoma of the bladder in 2008. In 2017, this person developed a benign meningioma in the temporal area of the brain. What is/are the Sequence Numbers? Texas Cancer Registry | Demographics and Patient Information

  42. Sequence NumbersPop Quiz A patient is diagnosed at your facility with colon cancer in 2018. The patient has a history of lung cancer diagnosed and treated elsewhere in 2011. What is/are the Sequence Numbers? Texas Cancer Registry | Demographics and Patient Information

  43. Sequence NumbersPop Quiz A patient was diagnosed with carcinoma of the stomach in 2016, squamous cell carcinoma of the left forearm in 2017, and non-Hodgkin’s lymphoma in 2018. What is/are the Sequence Numbers? Texas Cancer Registry | Demographics and Patient Information

  44. Other Primary Tumors • This data field documents tumors in patient’s lifetime • Document topography, morphology and diagnosis date • Document multiple primaries diagnosed synchronously • Do notdocument metastatic sites in this field • Add supporting text for record consolidation • This field can be blank if the sequence number is 00 for a malignant neoplasm or 60 for a non-malignant neoplasm Texas Cancer Registry | Demographics and Patient Information

  45. Primary Payer at Diagnosis • This information helps with financial analysis and an indicator for quality and outcome analyses • Payer is required by JCAHO on admit page • Record type of reported insurance. If there are multiple insurance carriers, record the first one • If the insurance carrier changes, do not change the initially recorded code Texas Cancer Registry | Demographics and Patient Information

  46. Examples ofPrimary Payer Texas Cancer Registry | Demographics and Patient Information

  47. Height and Weight • Height and weight are required for all cancer sites • Collect it from source records once for each cancer • Use value listed at or around time of diagnosis • Do not leave height and weight blank Texas Cancer Registry | Demographics and Patient Information

  48. Height and Weight Height Weight Texas Cancer Registry | Demographics and Patient Information

  49. Tobacco Use Use the following coding for all four tobacco fields: • Tobacco Use Cigarettes • Tobacco Use Other Smoke: pipes, cigars, kreteks • Tobacco Use Smokeless • Tobacco Use NOS Texas Cancer Registry | Demographics and Patient Information

  50. Tobacco Use • E-cigarettes • Battery operated inhaler • Contains nicotine (sometimes), flavoring, other chemicals • Does not contain tobacco • Do not code as Tobacco Use • Document it in the text Texas Cancer Registry | Demographics and Patient Information

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