From Abstract to From Abstract to Audit and Back Audit and Back AgainAgain

Nancy RoldMissouri Cancer Registry

MoSTRA Annual Meeting 2010

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) (#U58/DP000820-04) and a Surveillance Contract between DHSS and the University of Missouri.

To see ourselves as others see us,would from many a blunder free us.

-Robert Burns

OutlineOutline

Review Results◦National NPCR audit◦NPCR audit of MCR data◦MCR audits of hospital data

Strategies to Use◦Field specific recommendations to avoid occasional traps and pitfalls

National NPCR AuditNational NPCR AuditCompared select abstract data fields to source documents for all sites from 28 states

Cases diagnosed 2004-2006

Overall accuracy by state was 90-98% - Excellent!

NATIONAL NPCR AUDITNATIONAL NPCR AUDIT

CS Elements Errors by Diagnosis Year

Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis

NATIONAL NPCR AUDITNATIONAL NPCR AUDIT

Surgery Errors by Diagnosis Year

Source: NPCR presentation – Using Audit Results to Drive Education Opportunities by Mary Lewis

NPCR Audit of NPCR Audit of MCRMCR Data DataIn 2008, with the help of 9 Missouri

hospitals of varying size - Thank you!!

NPCR re-abstracted 297 MCR cases diagnosed in 2005 for Quality in 20 critical data fields

Casefinding was also audited to assess data for Completeness

NPCR Audit of NPCR Audit of MCRMCR Data Data

Overall data accuracy for Missouri was 95%

Overall completeness was 96.7%

NPCR Audit of NPCR Audit of MCRMCR Data Data

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

99.7% 98.7% 97.6% 96.0% 95.3%94.3% 93.6% 93.6% 93.6% 93.6%

88.2% 84.8%

73.1%

Accuracy Rates for Tumor-Specific Elements

Source: NPCR Data Completeness and Quality Audit of Missouri Cancer Registry – Diagnosis Year 2005

NPCR Audit of NPCR Audit of MCRMCR Data Data

Sites with the highest error rates ◦Lung 20%◦Breast 19%◦GI & Urinary15%

MCR Audits of MCR Audits of HospitalHospital DataDataMCR tries to audit every hospital within a 5 year cycle

Audits may include casefinding and/or re-abstraction/re-coding

Again, Thank You for participating!

MCR Re-Abstraction - MCR Re-Abstraction - SourcesSources2007 Hospital Data

Abstracts From Recent Transmittal(s)

Text - Source Document

MCR Re-Abstraction - MCR Re-Abstraction - OutcomesOutcomesPrimary Sites

Breast - Highest Incidence of Errors (10%)

Colorectal (8%)

Lung (6%)

MCR Re-Abstraction - MCR Re-Abstraction - OutcomesOutcomesField Coding Errors

CS Extension Highest Incidence of Errors (11%)

Grade, CS LNs, Rx Surgery Summary (10% Respectively)

Primary Site/Subsite, Dx Date (9% Respectively)

MCR Re-Abstraction - MCR Re-Abstraction - RecommendationsRecommendations

Enter Supporting Text Into the Abstract First Then Code the Data Items

Review Codes and Text Carefully to Ensure Each Substantiates the Other• Be Specific When Assigning Codes • Look Twice Before Assigning 9’s

MCR Re-Abstraction - MCR Re-Abstraction - ConclusionConclusion

Text to Code Auditing will be one of MCR’s standard audit methods

Keep in mind Supporting Text is required as explained in previously published MCR guidelines and now in the MCR Manual

MCR MCR CasefindingCasefinding Audit - Audit - PurposePurposeAffirm Case Completeness of Electronic Reporting Facilities – 2007 data

Special Emphasis on Evaluation of New Multiple Primary rules

Evaluate Hospital Casefinding Procedures, Patterns

Provide Education

MCR Casefinding Audit - MCR Casefinding Audit - SourcesSources

Twenty Facilities Reviewed - High, Medium, Low Categories

2007 MRDI Provided By Facility

2007 MCR Extract File Of Hospital Data

MCR Casefinding Audit - MCR Casefinding Audit - OutcomesOutcomes

Overall Results Were Very Good 95-100%

Fifteen Hospitals Met the Standard

1 Hospital Was 100% Complete!! 2 Hospitals Missed Only One Case!

MCR Casefinding Audit - MCR Casefinding Audit - FindingsFindings

Overall Case Completeness

Facility Type

Match Cases

Missed Cases

Matched & Missed

Per Cent Complete

All Total 5,092 218 5,310 95.89

Body System Number of

Found Cases Number of

Missed Cases Number Found

and Missed Percentage

Case Completeness

Respiratory System 1,057 33 1,090 96.97

Breast 825 28 853 96.72

Digestive System 952 26 978 97.34

Male Genital System 449 25 474 94.73

Endocrine System 110 17 127 86.61

Miscellaneous 93 17 110 84.55

HP Diseases 110 14 124 88.71

Non-Malignant CNS 106 13 119 89.08

Lymphoma 223 12 235 94.89

Reportable Skin 126 11 137 91.97

Female GU System 325 11 336 96.73

Urinary System 344 7 351 98.01

Oral Cavity / Pharynx 170 1 171 99.42

Bones and Joints 11 1 12 91.67

Brain / Nervous System 88 1 89 98.88

Myeloma 58 1 59 98.31

Soft Tissue / Heart 32 0 32 100

Eye and Orbit 4 0 4 100

Mesothelioma 9 0 9 100

Total 5,092 218 5,310 95.89

Casefinding – Casefinding – Types of Missed CasesTypes of Missed Cases

Clinically Diagnosed casesCases Diagnosed On Imaging

Cases Diagnosed on Biopsy Encounters for XRT, Chemotherapy, Hormonal Therapy

Majority Outpatient Cases

Casefinding - Reasons for Casefinding - Reasons for Missed CasesMissed Cases

Pathology Reports / OP Treatment Summaries Not Routed to Registry

No MRDI Review Inadequate MRDI ReviewIncomplete ICD-9 and Service Codes on MRDI

Casefinding - Casefinding - RecommendationsRecommendationsDo Not Limit Casefinding to Pathology Reports or Treatment Summary Referrals

Develop a Medical Record Disease Index

Run Separate MRDI’s To Capture Benign Brain/CNS Cases and Op Rx Cases

Casefinding - Casefinding - RecommendationsRecommendationsBe cognizant of

timeliness/completeness reminders

Notify MCR of late file submissions

Encourage electronic casefinding enhancements when feasible

CS Extension - ColonCS Extension - ColonPath: MD adenocarcinoma extending

through the subserosa into the pericolic fat

Code: 450 – Extension to pericolic fat

Not: 400 – Subserosal fat invaded or 420 – Fat, NOS

Source: CS Colon Schema

CS Extension - BladderCS Extension - Bladder

Path: Transitional cell carcinoma, non-invasive

Code:010- stated non-invasive

Not300 - localized, NOS

CS Extension - ProstateCS Extension - ProstateH&P: PSA elevated, DRE unremarkable,

biopsy recommended & done, stated cT1

Code: 150 – tumor identified by needle biopsy, e.g. for elevated PSA, clinically inapparent

Not999 – extension unknown

See CS schema notes – registrar should not infer whether tumor is apparent

CS – SSF 3 - ProstateCS – SSF 3 - ProstateCode based on first course

prostatectomy or autopsy findings, not the clinical findings coded in CS Extn

970 – no prostatectomy (RT consult notes may confirm this)

960 – unknown if prostatectomy doneAvoid use of 030 – Localized, NOS

when a more specific code applies (230 - both lobes)

CS – SSF 3 - ProstateCS – SSF 3 - Prostate

Path: Gleason 7 adenocarcinoma with extracapsular extension and positive margins

Code: 480 – extracapsular extension and positive margins

Not: 420 – unilateral extracapsular extension

CS Extension - LungCS Extension - LungRadiologic evidence of Pleural

Effusion was not properly coded as CS Extn 72 in several findings in the NPCR audit of MCR 2005 data.

NOTE: in 2010 pleural effusion is coded in CS Mets at DX (codes 15-18) for lung primaries and in SSF1 for Pleura primaries.

Read the CS coding notes carefully relative to your case.

CS Extension - ThyroidCS Extension - Thyroid

Path: two areas of papillary carcinoma in left thyroid lobe

Code: 200 - Multiple foci confined to thyroid

Not: 300 – local, NOS

CS Extension vs. MetsCS Extension vs. Mets

Op Note/Path: Lung cancer with direct extension into adjacent rib

Med Onc note: surgeon found rib mets

Code: CS Extn 730 – Adjacent ribNot: Mets at Dx 40

Text, Text, Text – to support

CS Lymph Nodes – Lung CS Lymph Nodes – Lung

CT scan: mediastinal mass suspicious for LN involvement

Code : 200 – Mediastinal, NOSNot: 999 - Unknown

For other terms that constitute clinical diagnosis of LN, see CS Manual, part 1section 1, pg 23.

CS Mets CS Mets 999 – Unknown may be an over-

used code000 should be used if the cancer

is stated to be early stage and tx is for such

Example: Localized lung cancer treated with surgery alone.

CS Mets CS Mets

For standard treatments by stage see:

http://www.nccn.org/professionals/physician_gls/f_guidelines.asp

Site - MeningesSite - Meninges

MRI of brain – probable meningioma

Site Code: C70.0 cerebral meninges

Not: C71.0 cerebrum

Subsite - BreastSubsite - Breast

On the NPCR audit of MCR data, breast accounted for 60% of the subsite discrepancies.

Subsite - BreastSubsite - Breast

Used by permission: April Fritz, A Fritz and Associates, LLC

Subsite - BreastSubsite - BreastC50.8

Single tumorOverlaps contiguous subsitesPoint of origin unknown

C50.9Multiple tumorsOrigins in different subsites of one breast, orNOS

Source: FORDS p. 107, ICD-O-3 p. 25

Subsite - BreastSubsite - Breast

Use of C50.9 - NOS may be a result of the lack of availability in the medical record.

Source: MCR data extract, Use of C50.9 by class of case in abstracts 2004-2008 as % of total breast sites.

Class 0 Class 1 Class 2 Class 3 overall

17% 15% 24% 60% 20%

C50.9 - MCR DataC50.9 - MCR Data

Histology – Colon PolypsHistology – Colon Polyps

Path: adenocarcinoma within a tubulovillous adenoma

Code: 8263 – Adenocarcinoma in a tubulovillous adenoma

Not: 8140 – Adenocarcinoma, NOS

Histology - Colon PolypsHistology - Colon Polyps

Histology - ThyroidHistology - Thyroid

Path for thyroid surgery: papillary carcinoma

Code: 8260 – papillary carcinoma (C73.9)

Not: 8050 – papillary carcinoma, NOS

Grade – Bladder (historic)Grade – Bladder (historic)Path: papillary urothelial

carcinoma, low gradeCode:

2 – moderately differentiatedNot:

1 – well differentiatedSimilarly high grade was coded to

04 undifferentiatedBUT….

Grade – Bladder – NEW!Grade – Bladder – NEW!August I&R question 48073:For Urothelial Bladder Primaries, stated

high or low grade:SSF 1 – records the grade (010 low, 020

high)Grade (6TH digit) is coded 9Grade Path System and Value = blank

FORDS p. 115 bullet 4, other sections to be clarified in next update

Grade - ProstateGrade - ProstatePath: adenocarcinoma, Gleason 6Code:

2- moderately differentiatedNot:

9 – unknownSource: FORDS p. 12

WD Gleason 2,3,4MD Gleason 5,6

PD Gleason 7-10

Grade – GI sitesGrade – GI sitesPath: liver biopsy – moderately

differentiated adenocarcinoma, consistent with colon primary

Code: 9 – grade of colon primary is unknown

FORDS p. 112Code the grade or differentiation from

the pathologic examination of the primary tumor, not from metastatic sites.

Biopsy vs. SurgeryBiopsy vs. SurgeryIncisional Biopsy

Op Note: breast core needle biopsyCode in Dx/Staging Procedure - 02 biopsy of primary site (a diagnostic procedure)

Excisional BiopsyOp Note: excisional biopsy of breast massCode in Surgery of Primary Site: 22

excisional biopsy (a treatment)

Surgery Code - Breast Surgery Code - Breast

Op Note: L total Mastectomy, no reconstruction

Code: 41 – Total Mastectomy WITHOUT removal of uninvolved contralateral breast

Not: 40 – Total Mastectomy

Surgery Code – Mastectomy, Surgery Code – Mastectomy, NOSNOS

MCR Data on Mastectomy Rates

Surgery Code - Breast Surgery Code - Breast Op Note: R simple mastectomy and

axillary LN dissection

Code: 51 - Modified Radical Mastectomy

Not: 41 - Simple Mastectomy

Source: FORDS p. 270 – simple mastectomy does not include an axillary dissection

LN Surgery Code – BreastLN Surgery Code – Breast

Op note: Three sentinel lymph nodes removed

Code: 2 – Sentinel lymph node biopsy

Not: 4 - 1-3 LN removed

Source: FORDS p. 225

LN Surgery Code - BreastLN Surgery Code - BreastOp Note: 5/1/10 - 2 sentinel lymph nodes removed,

pos5/8/10 – axillary LN dissection, 2/5 LN pos

Code: 7 – SLN and code 5, at different times

Not: 5 – four or more regional LN removed

Source: FORDS p. 225

Surgery Code and DateSurgery Code and DateOp Notes:4/5/10 Lumpectomy5/7/10 Simple Mastectomy

Code:Rx Date Surgery (First) & First Course

= 4/5/10Rx Summ Surgical Procedure of

Primary Site = 41 Simple Mastectomy (see FORDS – code most invasive procedure)

Surgery Code and DateSurgery Code and Date

Op Notes:4/5/10 Excisional biopsy5/7/10 Re-excision to clear margins

Code:Rx Summ Surgery of Primary Site – 23 – Re-excision

Surgery Code - Colon Surgery Code - Colon

Colonoscopy Report: polypectomy performed

Code: 28 - polypectomy, endoscopic

Not: 26 – polypectomy, NOS

Source: FORDS p. 255

Surgery Code – Rectal Surgery Code – Rectal Op Note: polypectomy via

electrocautery snare

Code: 22 - polypectomy, electrocautery

Not: 20 – local excision, or 26 – polypectomy (note: the highest code is not the most detailed)

Source: FORDS p. 259

Surgery Code - Prostate Surgery Code - Prostate H&P: TURP recommended for BPH

(benign prostatic hyperplasiaPath: incidental finding of prostate

adenocarinoma in 5% of resected tissue

Code: 22 – TURP – cancer is incidental finding during surgery for benign disease

Not: 21 – TURP, NOSSource: FORDS p. 278

Surgery Code - LymphomaSurgery Code - Lymphoma

CT scan – single suspicious supraclavicular node noted

Op Note/Path – excised node contains lymphoma

Code Surgery Primary Site - 25 Less than a full chain, includes excisional bx single LN

Date of First Course Date of First Course TherapyTherapyWhen there is a decision not to treat,

Missouri follows the CoC rules.

Code: the date the decision was made: 8/8/2010

Not blank, which is used only for autopsy only cases

Source: FORDS p. 211