Download This case is reportable. - Missouri Cancer Registry

Finding Cases
for Low Volume Hospitals
This training is provided by the
Missouri Cancer Registry
MCR gratefully acknowledges Louanne Currence, RHIT, CTR who
developed the Power Point presentation used as the basis for this
training and Debra Douglas, CTR who developed the policies and
procedures for cancer reporting by low volume hospitals.
Disclaimer- Missouri Cancer Registry presents this training as a learning
tool for hospital staff who report cancer cases to the central registry. This
tool should not be used to determine medical diagnoses. Persons seeking
CMEs or CEUs should check with their accrediting organization to
determine if this training meets their criteria for educational credits.
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) (#U55/CCU721904-05) and
a Surveillance Contract between DHSS and the University of Missouri.
Contact:
Brenda Lee
Case Finding
There are several Missouri laws
about cancer reporting.
leebra@health.
missouri.edu
573-882-8424
• Missouri Cancer Registry (MCR) Regulations
Reporting of cancer cases to the Missouri Department of Health
(now the Missouri Department of Health and Senior Services) for
Missouri hospitals became mandatory in 1984 when the State
General Assembly passed a bill to require inpatient reporting by
hospitals. Due to changes in the health care delivery system, an
increasing number of cancer cases are now being treated outside
the hospital setting. Therefore an expanded cancer reporting law
was passed in 1999 (RSMo 192.650, 192.653, 192.655, 192.657
and CSR 70-21.010[pdf]). This law requires that pathology
laboratories, ambulatory surgery centers, freestanding cancer clinics
and treatment centers, physicians and long-term care facilities also
report cancer cases.
Case Finding
The laws are applied to low-volume facilities as
follows:
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
• A hospital with 75 or fewer cases annually
is classified as low volume.
• low volume facilities:
– Identify potential cases, copy and submit
relevant parts of the medical record for
abstraction by central registry staff.
– Submit cases on a quarterly basis.
– Submit cases to MCR within 6 months of
patient’s initial contact with the facility.
Case Finding
•
•
•
The main role of low volume hospitals is case
finding & submitting charts in a complete and
timely fashion.
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
By law, facilities are required to report cases
diagnosed and/or treated for cancer in their
facility.
Unlike larger hospitals, low volume hospitals
are not required to submit fully-abstracted
cases electronically.
Related duties involve keeping complete
records of cases submitted, correspondence
from MCR, etc.
Contact:
Brenda Lee
Case Finding
Case-Finding Basics
leebra@health.
missouri.edu
573-882-8424
• Designate a specific person to perform
case-finding and allow adequate time to
identify cases, copy and submit charts.
• Conduct case-finding activities on a
regular basis at least quarterly.
• Collaborate with the laboratory and other
departments/sources that may provide
tumor information.
How do I identify
reportable cases?
Case Finding
Reportable Cases
●Inpatient and outpatient hospital
cases are required
●Cases with specified ICD-9 codes
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
In order to report a case to MCR, you first must be able to
determine if a case is eligible. Case eligibility is usually
determined by a combination of factors. These factors
include the behavior of the disease (benign, malignant,
in situ, etc.), and when and where the case is treated.
Look in the MCR Abstract Code Manual or on the MCR
website for a reportable list of the ICD-9 codes
(http://mcr.umh.edu/downloads/ICD-9-CM%20Low-Volume%20Codes.pdf). The
following slides discuss different aspects of how to
determine if you should report a case to MCR.
Contact:
Brenda Lee
Case Finding
If your facility owns the medical
record you should report the case!
leebra@health.
missouri.edu
573-882-8424
•
The general rule of thumb is that the hospital that owns the medical
record where the patient’s diagnosis and/or treatment occurs is the
facility required to report the case. For many low volume facilities, the
patient will be diagnosed in your facility, but referred elsewhere for
treatment. Examples:
•
A patient has a mammogram at your hospital and the radiologists says
the test is suspicious for breast cancer. The patient is referred to
another hospital for the biopsy. This case is reportable.
•
A patient has a colonoscopy at a surgery center owned by the hospital.
The test shows cancer. This case is reportable.
•
A patient is diagnosed with prostate cancer by a prostate biopsy
performed in a physician’s office whose practice is owned by your
hospital. This case is reportable.
Contact:
Brenda Lee
Case Finding
ICD-9-CM Inclusions and Exclusions
leebra@health.
missouri.edu
573-882-8424
While the ICD-9-CM list mainly includes
malignancies, there are a few inclusions
and exclusions you need to know.
Case Finding
Inclusion: Benign brain tumors are reportable
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
Beginning with cases diagnosed in 2004 benign brain
tumors are required to be reported to MCR.
Codes for benign brain tumors that must be reported are:
ICD-9-CM Codes
225.0 – 225.4 (for Benign Meninges and Brain)
225.8 – 225.9 (for Spinal Cord, Cranial Nerves and other)
227.3 – 227.4 (for other endocrine glands, etc.)
Case Finding
Exclusions: Some malignant tumors are NOT
reportable.
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
Basal Cell Carcinomas (BCC) and Squamous
Cell Carcinoma (SCC) of the skin are no longer
required to be reported. This includes ICD-9-CM
codes 173.3 – 173.9 skin cancers.
MCR does not require CIN (cervix) ICD-9-CM
233.1, PIN (prostate) ICD-9-CM 602.3.
Contact:
Brenda Lee
Case Finding
Tricky cases!!
leebra@health.
missouri.edu
573-882-8424
Cases of intraepithelial neoplasia can be
tricky.
MCR does require intraepithelial neoplasia
for all AIN (anal) ICD-9-CM code 154.2 –
154.3, Female Genital Organs 184.0 –
184.9 which includes VIN (vulvar) and
VAIN (vaginal) and Male Genital Organs
187.1 – 187.9.
Case Finding
Some terms used in reporting cases
can be ambiguous.
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
• Terms that designate a reportable case must always include a
reference to malignancy, cancer or other similar term, except when
the diagnosis is for a benign primary tumor of the intracranial region,
the brain or the central nervous system. Some specific ambiguous
terms that are used by physicians constitute a reportable diagnosis,
while others do not.
• These terms may originate from any source document such as
pathology, radiology, discharge summary and clinical reports and
may lead to minor problems during case finding because some
ambiguous terms for ICD-9 coding may not mean the same thing
regarding reporting status (i.e.: ‘possible’ cancer may be coded as a
malignancy by ICD-9 coders, but ‘possible’ is a non-reportable
ambiguous term for cancer reporting). When reviewing the medical
record, if ambiguous terminology is used in the diagnosis, refer to
the following lists to determine reporting status.
Case Finding
Some terms used in reporting test
results can be ambiguous.
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
If one of the following terms is used by the physician (in
combination with “malignancy” or “cancer”) , the case is
reportable:
“Apparently, Appears to, comparable with, compatible with,
consistent with, favors, malignant appearing, most likely,
presumed, probable, typical of and suspicious”
On the other hand, if one of these terms is used, the case
is NOT reportable:
“ Cannot be ruled out, equivocal, possibly, potentially
malignant, questionable, rule out, suggests and
worrisome”
Contact:
Brenda Lee
Case Finding
Examples of Ambiguous Terminology
leebra@health.
missouri.edu
573-882-8424
• CT scan results state “cancer cannot be
ruled out.” This is not reportable.
• CT scan results state “probable cancer.”
This is reportable.
What sources do I use
to identify cases?
Case Finding
Common places to look for
reportable cases include:
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
To identify reportable cases, it is essential to identify potential sources.
• Medical Records/HIM departments: These departments can produce
lists based on the patient’s diagnosis (ICD-9 codes) and/or the type
of procedure done for the patient (CPT codes). These lists are
commonly called medical records disease indices (MRDI).
• Laboratory reports: Pathology reports from surgical procedures are
a good source. Cytology reports from urine, sputum, fluids such as
spinal, pleural, ascites, etc. are also good sources to use when
looking for reportable cases. Pap tests are considered cytology, but
MCR does not require results from those procedures.
• Outpatient department lists: Patient lists from outpatient sites such
as same day surgery clinics, satellite clinics, etc. can provide
possible reportable cases. Clinic charts must be reviewed at least
annually, but it may be easier to do it more often (monthly or
quarterly).
Contact:
Brenda Lee
Case Finding
Using the Medical Record
Disease Index (MRDI) to locate cases
leebra@health.
missouri.edu
573-882-8424
• The MRDI is one of the most complete sources to locate reportable
cases. It must be designed to include codes to identify all potential
cases based on ICD-9-CM DIAGNOSIS CODES. For each
admission of the patient include THE TOP SIX ICD-9 CODES (see
MCR Abstract Code Manual or the MCR website for list of reportable
codes) and reviewed on a regular basis (at least quarterly). Do not
rely on non-specific activities such as discharge lists, memory or
charts being identified by coders.
• The report should be designed to include patient name, date of
birth, ICD-9-CM codes, procedure codes, admission type and
medical record number and sorted by patient name. If your
department does not have the capability to generate the report,
request assistance from your hospital’s IT department.
Case Finding
Using the pathology
report to locate cases
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
• The use of pathology reports will identify patients
diagnosed and treated for malignancies.
• Collaborate with staff in the pathology
department to route copies of all path reports
that mention a reportable diagnosis.
• Provide pathology department personnel with
the necessary information to identify cancer
cases.
• Some facilities may have electronic pathology
records that could be used to produce regular
reports.
Contact:
Brenda Lee
Case Finding
Other Sources
leebra@health.
missouri.edu
573-882-8424
• Outpatient listings
– Same-day surgery centers
– Satellite clinics
• ***Occasionally you will run across a chart that
provides evidence of a diagnosis in a physician’s
office. Cases generated by a patient having
been seen in a physician’s office (not owned by
the hospital) ONLY are optional to report at this
time.
Case Finding
Potential sources
continued
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
• Other potential sources:
– Specialty procedures for patients (such as
colonoscopies, bronchoscopies or
orchiectomies) that have a special procedure
code. You should be able to ask for a report
(at least annually) of patients receiving these
procedures.
What constitutes a
diagnosis?
Contact:
Brenda Lee
Case Finding
A diagnosis includes:
leebra@health.
missouri.edu
573-882-8424
• Positive pathology reports - examination
of tissue and blood.
– Tissue specimens - incisional biopsy,
excisional biopsy, surgical resection, autopsy
and D&C
– Bone Marrow biopsy – aspiration and biopsy
– For leukemia only – Peripheral blood smears,
CBCs, WBCs
Contact:
Brenda Lee
Case Finding
What constitutes a diagnosis?
leebra@health.
missouri.edu
573-882-8424
• Positive cytology reports - examination
of cells
– Bronchial brushings and washings, sputum
smears, pleural fluid, peritoneal fluid, spinal
fluid, gastric fluid, cervical and vaginal
smears, urinary sediment (Pap tests are
considered cytology, but MCR does not
require results from those procedures.)
Contact:
Brenda Lee
Case Finding
Diagnosis continued:
leebra@health.
missouri.edu
573-882-8424
Positive radiology tests – these tests may
contain ambiguous terminology & may
require additional manpower for review.
– Mammograms
– Chest x-rays
– CT scans
– MRIs
– Ultrasound
How do you define
treatment?
Contact:
Brenda Lee
Case Finding
Definition of treatment
leebra@health.
missouri.edu
573-882-8424
Treatment or therapy for cancer modifies,
controls, removes or destroys cancer tissue. The
first course of treatment includes all cancerdirected treatments indicated in the initial
treatment plan which are actually delivered to
the patient. A decision not to treat or refusal by
the patient to accept treatment is considered a
treatment plan, as is palliative care. These
patients are all reportable to MCR.
Contact:
Brenda Lee
Case Finding
Examples of treatment
leebra@health.
missouri.edu
573-882-8424
• Reportable cases:
– During a colonoscopy at another facility a
patient is diagnosed with colon cancer. The
patient has a part of the colon removed at
your facility.
– The patient is admitted to your facility during a
course of chemotherapy for low blood counts.
During the hospital stay, the patient receives
chemotherapy.
Case Finding
Exclusions – these are not
reportable:
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
Not reportable
• A patient is diagnosed with colon cancer at another
hospital. He comes to your facility for a follow-up annual
colonoscopy.
• A patient is receiving chemotherapy at another
hospital/facility. Due to complications or another health
condition, the patient is hospitalized at your facility.
• The patient is coded as having a “history of cancer” in
ICD-9.
• Your facility is caring for a patient who has active or
metastatic cancer but is not receiving treatment but may
be receiving hospice care for the cancer at your facility.
Contact:
Brenda Lee
Case Finding
Keeping Track…
leebra@health.
missouri.edu
573-882-8424
• A Control Log of charts that have been
submitted to MCR must be maintained.
• This log should include:
–
–
–
–
–
–
–
Patient name
Date of birth
Social security number
Reporting year
ICD-9 codes
Encounter date(s)
Date submitted to MCR
Contact:
Brenda Lee
Case Finding
Other Documentation
leebra@health.
missouri.edu
573-882-8424
• Copies of pathology reports, new patient
listings, end of treatment notes,
monthly/quarterly disease index and other
logs and discrepancy files may be
maintained as desired by the facility.
• All case-finding files should be secured
per HIPAA regulations to prevent
unauthorized access to patient
information.
Contact:
Brenda Lee
Case Finding
Use of a “non-reportable” list
leebra@health.
missouri.edu
573-882-8424
• To further assist with case-finding activities and
possibly eliminate the need to pull a chart
multiple times, a non-reportable list can be
maintained. This is a list of cases that have been
reviewed and found to be non-reportable.
• This list should include:
–
–
–
–
–
Patient name
Date of birth or social security number
Encounter date(s)
ICD-9 codes
Brief reason case is non-reportable
Case Finding
Key Elements to Remember
Contact:
Brenda Lee
leebra@health.
missouri.edu
573-882-8424
1.
2.
3.
4.
Identify potentially reportable patients
Locate the charts and other data
Review for reporting status
Copy pertinent chart documents for
reportable cases
5. Transmit the data to MCR at least
quarterly
6. Maintain suspense and control logs
Contact:
Brenda Lee
Case Finding
In Summary
leebra@health.
missouri.edu
573-882-8424
• Case-finding should be considered a priority of the
Health Information Management (or other designated)
department.
• A specific person should be designated to perform
case- finding. That person should be given adequate
time to identify, copy and submit charts.
• Case-finding activities must be conducted on a regular
basis (at least quarterly).
• MCR must be informed of any staff turnover or
changes.
Contact:
Brenda Lee
Case Finding
And don’t forget ---
leebra@health.
missouri.edu
573-882-8424
• A Transmittal Form must be submitted for
each reporting period (quarterly) even if no
charts are being sent.
• Please contact MCR if data submission for
any reporting period is going to be late.
• Call MCR at 1-800-392-2829 with questions –
we’re glad to help!!
• http://mcr.umh.edu/