1 / 42

Casefinding

Learn about the methods, sources, and process of casefinding in the Texas Cancer Registry, including reportable and non-reportable neoplasms. Gain helpful insights and hints for effective casefinding.

russellp
Download Presentation

Casefinding

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Casefinding Texas Cancer Registry

  2. Objectives By the end of this training, you should be able to discuss: • Casefinding Methods • Casefinding Sources • Casefinding Process • Reportable and Non-Reportable Neoplasms • Ambiguous Terms • Helpful Casefinding Hints Texas Cancer Registry | Casefinding

  3. Casefinding Definition of Casefinding (case ascertainment): Process of identifying all reportable cases through review of source documents and case listings. Casefinding covers a range of cases that need to be assessed to determine whether or not they are reportable. Cases reportable to the TCR are: • All neoplasms with a behavior code of 2 (in situ) or 3 (malignant) in the ICD-O-3 with some exceptions. • All primary tumors with behavior code of 0 (benign) or 1 (borderline) for central nervous system (CNS) cases DX in 2004 and later. Texas Cancer Registry | Casefinding

  4. Casefinding Methods There are two types of casefinding methods: 1. Active casefinding: The personnel responsible for reporting obtain and review all sources for eligible cases. This method is more comprehensive and precise. 2. Passive casefinding: The personnel responsible for reporting rely on others to notify the reporter of possible eligible cases. There is a greater potential for missed cases using this method. Texas Cancer Registry | Casefinding

  5. Casefinding Sources • HIM (medical records department) • Disease index • Admission and discharge reports • Pathology -- histology, cytology, hematology, autopsy and bone marrow reports • Surgery • Outpatient Departments • Medical & Diagnostic imaging • Radiation Oncology • Medical Oncology/Hematology • Emergency Room reports • Lab Reports Texas Cancer Registry | Casefinding

  6. Disease Index • Medical record number • Patient name • Date of birth • Social Security number • Sex • Patient Class/Type • Admission date • Discharge date • ICD-10 code/diagnosis description • * After DI is compiled it is recommended to include accession # and non-reportable columns Texas Cancer Registry | Casefinding

  7. Disease Index Example Texas Cancer Registry | Casefinding

  8. Non-Reportable codes 01 – Benign 02 – Non-Reportable Skin Cancer 03 – No Evidence of Disease (NED) 04 – Cancer Not Proven 05 – Duplicate Case 06 – In situ Cancer of Cervix, CIN III 07 – No Cancer Mentioned in Record 08 – Diagnosed prior to 1995 09 – Lab only 10 – Other (Include Explanation) Texas Cancer Registry | Casefinding

  9. Case ReportabilityPop Quiz Patient with a recent excisional biopsy for melanoma of skin of arm is admitted to your facility for a wide excision. The pathology report shows no residual melanoma. Is this case reportable? Why or why not? Texas Cancer Registry | Casefinding

  10. Case ReportabilityPop Quiz A patient comes to a facility for a bone scan. The facesheet has been coded to prostate cancer. The bone scan is negative and there is no other information to indicate that this patient has active disease or is receiving cancer directed treatment. Is this case reportable? Why or why not? Texas Cancer Registry | Casefinding

  11. Case ReportabilityPop Quiz A patient is admitted to the hospital after a heart attack. The chart states the patient has a history of prostate cancer and is on Lupron. There is no other information regarding the patient’s history. Is this case reportable? Why or why not? Texas Cancer Registry | Casefinding

  12. Casefinding Process • Obtain Parameter Listing • Obtain Disease Index • Request TCR Facility Data Report • Compare the patients with reportable codes on the disease index to the TCR Facility Data Report. • Identify Reportable & Non-Reportable Cases Texas Cancer Registry | Casefinding

  13. Comprehensive & Supplementary Lists • Intended to aid appropriate staff in creating the disease index (DI) with the required reportable neoplasms and ICD-10-CM codes • Two Separate DI’s must be requested: • DI with comprehensive reportable ICD-10-CM codes: Inpatient & Outpatient admissions based on ICD-10-CM Primary and Secondary diagnosis codes • DI with supplementary ICD-10-CM codes: Helps determine additional review for the facility Texas Cancer Registry | Casefinding

  14. Example of Comprehensive ICD-10-CM Codes Texas Cancer Registry | Casefinding

  15. Example of Supplementary ICD-10-CM Codes Texas Cancer Registry | Casefinding

  16. Other Casefinding Sources • Pathology - histology, cytology, hematology, autopsy and bone marrow reports • Medical & Diagnostic imaging • Lab Reports • Surgery • Radiation Oncology • Medical Oncology/Hematology • Outpatient Departments • Emergency Room reports Texas Cancer Registry | Casefinding

  17. Casefinding Sources • Cases diagnosed clinically are reportable. • Use clinical diagnosis when you do not have histology or cytology confirmation of a reportable diagnosis. • Information may be recorded in final diagnosis, clinic note, x-ray report, or other parts of the medical record. • A pathology report normally takes precedence over a clinical diagnosis. • If the physician treats a patient for cancer in spite of a negative biopsy, abstract the case. Texas Cancer Registry | Casefinding

  18. Case ReportabilityPop Quiz In February a patient has a CT that shows possible lung cancer. The physician states this is probably lung cancer. A fine-needle aspiration is non-diagnostic and the physician advises the patient to have further tests. The patient refuses any further work-up or treatment. In September the physician sees the patient again and states that this is probable lung cancer based on previous x-rays, continued symptoms, and further decline in health. Is this reportable? Why or why not? Texas Cancer Registry | Casefinding

  19. Case ReportabilityPop Quiz Positive histology from needle biopsy followed by negative resection. Is this reportable? Why or why not? Texas Cancer Registry | Casefinding

  20. Reportable Neoplasms • Malignant neoplasms with a behavior code of /2 or 3 with some exclusions • Benign and borderline neoplasms of CNS diagnosed as of 2004 • Pituitary adenomas diagnosed as of 2004 • Carcinoma in-situ (except cervical) • Carcinoid, NOS (changed starting 1/1/2015) • Non-invasive mucinous cystic neoplasm of the pancreas • Solid pseudopapillary neoplasm of the pancreas Texas Cancer Registry | Casefinding

  21. Reportable Neoplasms • Cystic pancreatic endocrine neoplasm • Mature Teratoma of the testes in adults • Pilocytic/juvenile astrocytoma • Lobular carcinoma in situ of breast • Reportable Intraepithelial neoplasia, grade III • GIST tumors and thymomas if evidence of multiple foci, lymph node involvement or metastasis • Urine cytology positive for malignancy (2013 and forward) Texas Cancer Registry | Casefinding

  22. Reportable Neoplasms • Reportable skin tumors • Adnexal carcinomas • Sweat gland • Ceruminous gland • Hair follicle • Adenocarcinomas • Lymphomas • Melanomas • Sarcomas • Merkel cell tumor • Any carcinoma arising in a hemorrhoid • Malignant neoplasms of skin of genital sites Texas Cancer Registry | Casefinding

  23. Diagnosis Prior to Birth • Diagnoses made in utero are reportable only when the pregnancy results in a live birth. • In the absence of documentation of stillbirth, abortion or fetal death assume there was a live birth and report the case. • When a reportable diagnosis is confirmed prior to birth and disease is not evident at birth due to regression, abstract the case based on pre-birth diagnosis. Texas Cancer Registry | Casefinding

  24. Brain and CNS Tumors • All diagnosis of the brain & CNS (C70_) must have a morphology term code listed in the ICD-O-3. • Only the terms tumor and neoplasm: • Are reportable for brain & CNS • Histology is coded 8000/0 for benign and 8000/1 for Neoplasm, NOS • Benign & borderline CNS cases diagnosed before 2004 are not submitted to the TCR • Consult Table 3.1 in TCR Handbook for required sites Texas Cancer Registry | Casefinding

  25. Reportable Examples • “A brain or a CNS neoplasm identified only by diagnostic imaging.” Neoplasm and tumor are reportable terms for brain and CNS because they are listed in ICD-O-3 with behavior codes of /0 and /1 • “Ovarian mucinous borderline tumor with foci of intraepithelial carcinoma.” This case is reportable because there are foci of intraepithelial carcinoma (carcinoma in situ). • “Biopsy-proven squamous cell carcinoma of the nipple with a subsequent areolar resection showing foreign body granulomatous reaction to suture material and no evidence of residual malignancy in the nipple epidermis.” This case is reportable. The fact that no residual malignancy was found in the later specimen does not disprove the malignancy diagnosed by the biopsy. Texas Cancer Registry | Casefinding

  26. Non-Reportable Neoplasms • Basal and squamous cell carcinomas of skinexcept for genital sites • Epithelial carcinomas of skin • Papillary and squamous cell carcinomas of the skin except for genital sites • Malignant neoplasms, NOS of skin • SIN III of the cervix • In situ neoplasms of the cervix • Intraepithelial neoplasms of cervix or prostate (CIN III & PIN III) • Borderline cystadenomas • Benign and borderline CNS cases diagnosed prior to 2004 Texas Cancer Registry | Casefinding

  27. Non-Reportable Neoplasms • Mass and lesion are not reportable terms for brain and CNS because they are not listed in ICD-O-3 with behavior codes of /0 or /1 • Squamous cell carcinoma of the perianal skin (C445) • Cholesteatoma in the cerebral meninges is not a reportable CNS case since there is no code for cholesteatoma listed in ICD-O-3. • The terms "high grade dysplasia" (HGD) and "severe dysplasia" is not reportable unless the pathologist documents carcinoma in situ or intraepithelial neoplasia grade III. • Intraepithelial Neoplasia • AIN II-III or II/III • VAIN II-III or VAIN II/III • VIN II-III or VIN II/III • Do not report even if patient is receiving treatment Texas Cancer Registry | Casefinding

  28. Ambiguous Terms For Reportability of Solid Tumors • Apparent(ly) • Appears • Comparable with • Compatible with • Consistent with • Favor(s) • Malignant appearing • Most Likely • Presumed • Typical (of) • Suspect (ed) • Suspicious (for) • Probable • Neoplasm (CNS Only) • Tumor (CNS Only) Texas Cancer Registry | Casefinding

  29. Ambiguous Terms: Reportability • If any of the reportable ambiguous terms precede a word that is synonymous with an in situ or invasive tumor, abstract the case. • Abstract the case based on the reportable ambiguous term when there are both reportable and non-reportable ambiguous terms in the medical record. • Do not abstract the case when the original source document used a non-reportable ambiguous term and the subsequent documents refer to the history of cancer. Texas Cancer Registry | Casefinding

  30. Ambiguous Terms: Brain and CNS (/0, /1) Abstract the case • If a reportable term precedes the word tumor or neoplasm • When both reportable and non reportable ambiguous terms are used abstract based on reportable term Do not abstract the case • When subsequent documents refer to history of tumor and the original source document used a non-reportable ambiguous term • If a resection, excision, biopsy, cytology or physician’s statement proves the ambiguous diagnosis is not reportable Texas Cancer Registry | Casefinding

  31. Ambiguous Terms: Cytology • Ambiguous terms are not diagnostic for cytology. • A positive urine cytology is reportable as of January 2013 (no ambiguous terms). • If there’s no information about primary site, code to C68.9 • If subsequent biopsy of urinary site is negative, do not report the case • For 2013 diagnoses and forward, do not implement new/additional casefinding methods Texas Cancer Registry | Casefinding

  32. Ambiguous Terms: Cytology Examples • A patient with persistent hematuria has a urinalysis done in your facility and the cytology report states cells suspicious for malignancy. The patient does not return for any further work-up. • Do not report this case based on the suspicious cytology alone. Follow back on cytology diagnoses using ambiguous terminology is strongly recommended. Texas Cancer Registry | Casefinding

  33. Ambiguous Terms: Cytology Examples • A fine needle aspirate of a thyroid nodule is suspicious for follicular carcinoma. The patient has a thyroid biopsy which shows papillary follicular carcinoma. • This case should be reported because the biopsy was positive for malignancy. Texas Cancer Registry | Casefinding

  34. Casefinding for Hematopoietic and Lymphoid Neoplasms See the reportability instructions for hematopoietic and lymphoid neoplasms at: http://www.seer.cancer.gov/seertools/hemelymph Per the Hematopoietic and Lymphoid Neoplasm Coding Manual (page 23), use the ambiguous terms when screening all reports other than cytology and tumor markers as of January 2013. Texas Cancer Registry | Casefinding

  35. Casefinding Tips • Reportable cases/active cancer • Consult only - Reportable • History of cancer – Might be reportable • Imaging reports – Look for diagnostic term • Lab-only cases – Usually not reportable Texas Cancer Registry | Casefinding

  36. Casefinding Hints • Review: • Pathology reports and disease indices monthly • Radiation oncology logs weekly • Outpatient and ER lists • Coders should route medical charts (cancer patients) to the registrar • Maintain non-reportable case list • For more information on submitting cases, visit the TCR Website: www.dshs.state.tx.us/tcr Texas Cancer Registry | Casefinding

  37. Case ReportabilityPop Quiz In 2018 a patient comes to your facility for a colonoscopy. The record states that the patient was diagnosed with breast cancer in 2014. she is still being treated with Tamoxifen which is the first course of treatment. It is unknown if the patient has evidence of disease at this time. Is this reportable? Why or why not? Texas Cancer Registry | Casefinding

  38. Case ReportabilityPop Quiz Esophageal biopsy with diagnosis of “focally suspicious for adenocarcinoma in situ”. Diagnosis on partial esophagectomy specimen “with foci of high grade dysplasia; no invasive carcinoma identified”. Is this reportable? Texas Cancer Registry | Casefinding

  39. Case Reportability Pop Quiz • Basal cell carcinoma of the skin • Hemangioma, NOS in the dura • In situ neoplasm of the cervix • Benign tumor of the cranial bones Which one is reportable? Texas Cancer Registry | Casefinding

  40. Case Reportability Pop Quiz • VAIN III • Venous angiomas of the brain • Urine cytology positive for malignancy • Pituitary adenomas Which one is not reportable? Texas Cancer Registry | Casefinding

  41. Summary You should now be able to discuss: • Casefinding Methods • Casefinding Sources • Casefinding Process • Reportable and Non-Reportable Neoplasms • Ambiguous Terms • Helpful Casefinding Hints Texas Cancer Registry | Casefinding

  42. Thank you Texas Cancer Registry | Casefinding

More Related