Electronic Reporting for Urology Physician Practices

Instructions and Reporting RequirementsModule 2Electronic ReportingForFacilitiesMarch 2014

North Carolina Central Cancer Registry

State Center for Health StatisticsDivision of Public HealthDepartment of Health and Human Services1908 Mail Service CenterRaleigh, NC 27699-1908http://www.schs.state.nc.us/units/ccr/

North Carolina Central Cancer Registry

Hello,

This is Ashanti Scott-Prince again and I will be your trainer. You are now entering training module two which will review Part II: Reporting Requirements of the Electronic Reporting for Facilities training manual.

As before, this training session was produced by the North Carolina Central Cancer Registry (NCCCR) to guide you on how to use the New Case Abstract form for facilities.

1Part II: Reporting Requirements

As noted in Module 1, the North Carolina Central Cancer Registry (NCCCR) collects, processes, and analyzes data on all cancer cases diagnosed among North Carolina residents. This is primarily a cancer surveillance activity, monitoring the incidence of cancer among the various populations of the state.All health care providers are required by law to report cases to the NCCCR (as in nearly all other states). Traditional data collection for central cancer registries has been primarily from hospitals. As medical advances have occurred, diagnosis and treatment of certain cancers has moved from the acute care setting to being fully cared for within the physician/clinic office and, therefore, never received and counted. Examples include melanoma of the skin; prostate cancer; and many hematopoietic malignancies like chronic lymphocytic leukemia, polycythemia vera and myelodysplastic syndrome. The NCCCR supplements hospital data with reports from physician/clinic offices who diagnose cases that are not seen in a hospital. In addition, death certificates and pathology laboratory reports are used to help identify cases that are missed in this routine reporting by hospitals and physician/clinic offices. Any duplicate reports are consolidated in the data editing process. The purpose of this concerted effort is to alleviate under-reporting or a delay in reporting which can adversely affect incidence rates and research from incomplete data collection.

Please ensure you have your Electronic Reporting for facilities training manual open to follow along or printed out to use for note taking.

2Part II: Reporting RequirementsSection II.1: Reporting ProceduresMUST use the New Case Abstract Form to report an eligible case of cancer One for each independent primary tumorA separate report must be completed and submitted for each primary tumor.Example: If a patient is diagnosed with bladder cancer and a separate kidney cancer, a separate report must be submitted for each diagnosis.Accuracy and thorough, complete reporting is necessaryPlease complete the form as ACCURATELY and COMPLETELY as possible.Once the report is free of errors and is successfully submitted, it is considered as having been reported to the NCCCRCopies of the medical record, paper version of the reporting form, or lists of reported patients are not required to be sent to the NCCCR.

The topic for this module, PART II: REPORTING REQUIREMENTS, is divided into three sections. Section II.1: Reporting ProceduresSection II.2: Cases Required to be Reported and Section II.3: Cases NOT Required to be Reported

We will begin now with Section II.1: Reporting Procedures.

To report an eligible case of cancer, the on-line Eureka New Case Abstract form must be used. A separate report must be completed and submitted for each independent primary tumor. For example, if a patient is diagnosed with bladder cancer and a separate kidney cancer, a separate report must be submitted for each diagnosis.Accuracy and thorough, complete reporting is necessary! Please complete the electronic reporting form as ACCURATELY and COMPLETELY as possible. Once the report is free of errors and is successfully submitted, it is considered as having been reported to the NCCCR. Copies of the medical record, paper version of the reporting form, or faxed lists of reported patients are not required to be sent to the NCCCR.

We will review HOW to report using the form in subsequent Sections. The main point to take away from this section is that you understand how important it is to have accurate and complete data. The screen has built-in programming which will help to identify when there are errors or discrepancies in the data entered.

3Part II: Reporting RequirementsSection II.1: Reporting Procedures - continuedBrief summary of steps required to report cases. Each step will be described in detail throughout the document and this training.Obtain a Eureka account for each facility.Obtain a Eureka user id and password for each staff person designated to report cases. Consider limiting this to two or three staff per facility.Each user MUST have a personal user id and password.Identify potential cases using the suggested casefinding procedures.Determine if the case should be reported using the case eligibility criteria.Access the electronic New Case Abstract form to enter and submit cases using the required data-entry specifications.Track cases that have been reported to avoid duplicate reporting.

Continuing with PART II: REPORTING REQUIREMENTS in the Electronic Reporting for Facilities training manual, Section II.1: Reporting Procedures.The following provides a brief summary of the steps required to report cases. Each of these steps will be described in detail throughout the document and this training. If you follow this order, ensuring you have completed each step required, you will be on your way to submitting cases as required.Obtain a Eureka account for each facility.Obtain a Eureka user id and password for each staff person designated to report cases. Consider limiting this to two or three staff per facility. Each user MUST have a personal user id and password.Identify potential cases using the suggested casefinding procedures.Determine if the case should be reported using the case eligibility criteria. Access the electronic reporting form to enter and submit cases using the required data-entry specifications. Track cases that have been reported to avoid duplicate reporting.These steps will be more thoroughly explained in later segments of this training.4Part II: Reporting RequirementsSection II.2: Cases Required to be ReportedAll health care facilities and providers are required to report:Eligible cancer cases and Non-malignant Central Nervous System (CNS) tumors, including:Brain, meninges and other CNS that are screened, diagnosed, treated or seen with evidence of cancer.Clinically diagnosed cases (not histologically confirmed)

We now move to Section II.2: Cases Required to be Reported of the Electronic Reporting for Facilities training manual.

One of the critical pieces of case reporting is to know what is reportable. The overall topic for this and the next few slides is reporting is required for all reportable diagnoses that meet specific criteria.

The next few slides provide a brief overview of what is or is not reportable. Rest assured we will provide more detail to assist you in later slides.

In North Carolina all health care facilities and providers are required to report:Eligible cancer cases

Non-malignant Central Nervous System (CNS) tumors includingBrain, meninges and other CNS that are screened, diagnosed, treated, or seen with evidence of cancer

and

Clinically diagnosed cases (not histologically confirmed)

5Part II: Reporting RequirementsSection II.2: Cases Required to be ReportedAll health care facilities and providers are required to report:Clinically diagnosed cases (not histologically confirmed)Consider the following as equivalent:TumorMassLesionNeoplasm

Continuing with Section II.2: Cases Required to be Reported of the Electronic Reporting for Facilities training manual.An addition to reporting eligible cancer cases and non-malignant Central Nervous System (CNS) tumors (including brain, meninges, and other CNS) that are screened, diagnosed, treated, or seen with evidence of cancer, and clinically diagnosed cases (not histologically confirmed) must also be reported.

Consider the following terms as equivalent: tumor, mass, lesion, neoplasm.

Therefore, reporting is required for all cancer diagnosed cases.6Part II: Reporting RequirementsSection II.2: Cases Required to be Reported - continuedReporting is required for all diagnoses that meet the following criteria - continued:Cell Type / Histology:Any tumor/condition described as:MalignantCancerCarcinoma (adenocarcinoma, transitional cell carcinoma, etc.)SarcomaMelanomaLymphomaLeukemiaIntraepithelial Neoplasia, Grade III (8077/2) of the following sites:Anal (AIN III)Vaginal (VAIN III)Vulvar (VIN III)

Reporting is required for all cancer diagnoses that meet the following criteria listed on this and the following slides. This page begins to review the Cell Type or Histology.

You can consider these as reportable if the Cell Type or Histology is described as:

Any tumor/condition described as:MalignantCancerCarcinoma (adenocarcinoma, transitional cell carcinoma, etc.)SarcomaMelanomaLymphomaLeukemiaIntraepithelial Neoplasia, Grade III (8077/2) of the following sites:Anal [AIN III]Vaginal [VAIN III]Vulvar [VIN III]

7Part II: Reporting RequirementsSection II.2: Cases Required to be Reported - continuedReporting is required for all diagnoses that meet the following criteria - continued:Cell Type / Histology:Squamous cell carcinoma originating in a mucoepidermoid site:

Lip C00.1 C00.9Vagina C52.9Anus C21.0Prepuce C60.0Labia C51.0 C51.1Penis C60.1 C60.9Clitoris C51.2Scrotum C63.2Vulva C51.9

This slide continues a review of aspects of CRITERIA for all cancer diagnoses you should be reporting for, specifically Cell Type / Histology.

You can consider these as reportable if the Cell Type or Histology is described as:

Squamous cell carcinoma originating in a mucoepidermoid site:Lip C00.1 C00.9Anus C21.0Labia C51.0Clitoris C51.2Vulva C51.9Vagina C52.9 Prepuce C60.0Penis C60.1 - C60.9 Scrotum C63.2

8Part II: Reporting RequirementsSection II.2: Cases Required to be Reported - continuedReporting is required for all diagnoses that meet the following criteria - continued:

Behavior Code:Tumors that are invasive (ICD-O-3 Behavior code of /3)Tumors that are in-situ (ICD-O Behavior code of /2)If the usual behavior code is /0 (benign) or /1 (uncertain) but a pathologist designates the tumor as in-situ or malignant, these cases are reportable.

Another important aspect of reporting is the Behavior Code. The Behavior Code is defined by the International Classification of Disease for Oncology, 3rd Edition (ICD-O-3). If the diagnosis has been given one of these Behavior Codes, consider the case reportable. The diagram on this slide indicates where the Behavior Code can be found. We will talk in more detail about this on the next slide. However, use these as an overall guide:

Tumors that are invasive will have an ICD-O-3 Behavior code of /3Tumors that are in-situ will have the ICD-O-3 Behavior code of /2If the usual behavior code is /0 (benign) or /1 (uncertain) but a pathologist designates the tumor as in situ or malignant, these cases are reportable.

9Part II: Reporting RequirementsSection II.2: Cases Required to be Reported - continuedReporting is required for all diagnoses that meet the following criteria - continued:Behavior Code - continued:International Classification of Disease for Oncology, 3rd Edition (ICD-O-3) Dual classification used principally in cancer registries with coding systems for bothTopography (site) andMorphology(histology)Describes characteristics of the tumor itself, including its cell type and biologic activityMorphology axis on the diagram provides five-digit codes ranging from M-8000/0 to M-9992/3.First four digits indicate the specific histological termFifth digit after the slash (/) is the behavior code Indicated whether a tumor is malignant, benign, in situ, or uncertain (if benign or malignant)Separate one-digit code is provided for histologic grading (differentiation).

We continue with the topic of Reporting is required for all cancer diagnoses that meet the following criteria.

Specifically, we continue with the Behavior Code:

The Behavior Code is defined by The International Classification of Disease for Oncology, 3rd Edition (ICD-O-3) which is a dual classification used primarily in cancer registries with coding systems for both topography (site) and morphology (histology).

You can see by the diagram that the royal blue color shows the cell type or morphology code. The morphology code describes the characteristics of the tumor itself, including its cell type and biologic activity. The morphology axis provides five-digit codes ranging from M-8000/0 to M-9992/3. The first four digits indicate the specific histological term.

The bright yellow section of the diagram shows the fifth digit after the slash (/) which is the behavior code, which indicates whether a tumor is malignant, benign, in situ, or uncertain (if benign or malignant).

The aqua section of the diagram shows a separate one-digit code that is also provided for histologic grading (differentiation).

10Part II: Reporting RequirementsSection II.2: Cases Required to be Reported continuedReporting is required for all diagnoses that meet the following criteria - continued:Diagnostic Confirmation (Method used to confirm the diagnosis)Histologically confirmed casesTissue examined and confirmed to be cancerCytologically confirmed casesFluid examined and confirmed to be cancer

Continuing with Section II.2: Cases Required to be Reported we move to the topic of Diagnostic Confirmation or Method used to confirm the diagnosis is discussed.

This is a continuation of the topic: Reporting is required for all cancer diagnoses that meet the following criteria with one more aspect of the criteria. Diagnostic Confirmation or the Method used to confirm the diagnosis is important to ensure validity of the diagnosis.

Most diagnosed cases have been confirmed using at least one of the following:Histologically confirmed cases are cases where tissue was examined and confirmed to be cancer.Cytologically confirmed cases are cases where fluid was examined and confirmed to be cancer.And, Clinically diagnosed cases which are cases confirmed by means other than microscopic examination such as positive radiology or laboratory results. (which will be reviewed on the next slide)

11Part II: Reporting RequirementsSection II.2: Cases Required to be Reported continuedReporting is required for all diagnoses that meet the following criteria - continued:Diagnostic Confirmation (Method used to confirm the diagnosis)Clinically diagnosed casesConfirmed by means other than microscopic examination Such as positive radiology or laboratory resultsA diagnosis must be reported even if it has not been microscopically confirmed.If the physician states the patient has cancer, the case is reportable If the diagnosis could not be definitively confirmed but is being treated as a malignancy, the case is reportable.

Continuing with Diagnostic Confirmation or the Method used to confirm the diagnosis is important to ensure validity of the diagnosis. Most diagnosed cases have been confirmed using at least one of the following:

In the last slide we reviewed:Histologically confirmed cases are cases where tissue was examined and confirmed to be cancer.Cytologically confirmed cases are cases where fluid was examined and confirmed to be cancer.

Here we introduce the third diagnostic confirmation: Clinically diagnosed cases which are cases confirmed by means other than microscopic examination such as positive radiology or laboratory results. It is important to note that a diagnosis must be reported even if it has not been microscopically confirmed.If the physician states the patient has cancer, the case is reportable.If the diagnosis could not be definitively confirmed but is being treated as a malignancy, the case is reportable.

12Part II: Reporting RequirementsSection II.3: Cases NOT Required to be Reported The following types of cases are not required to be reported:Prostate Intraepithelial Neoplasia, Grade III (PIN III) 8148/2Cervix Intraepithelial Neoplasia, Grade III (CIN III) 8077/2Carcinoma in situ (CIS) of the cervix only. All other in situ cases are reportable.Basal and Squamous cell cancers (histology codes: 8000-8110) of the skin only (site code: C44._ only) are not reportableBasal cell and squamous cell cancers of any other site are reportableSkin of labia (C51.0), vulva (C51.9), penis (C60.9) and scrotum (C63.2) are reportablePatients seen only in consultation to provide a second opinion to confirm a diagnosis or a treatment plan.Patients in remission (there is no evidence of active disease) and not receiving prophylactic or adjuvant therapy.

We now move to Section II.3: Cases NOT Required to be Reported of the Electronic Reporting for Facilities training manual.This is a full slide but we thought it would be helpful for you to see all of these exceptions in one location.

The following types of cases listed on this slide are not required to be reported: Prostate Intraepithelial Neoplasia, Grade III (PIN III) 8148/2Cervix Intraepithelial Neoplasia, Grade III (CIN III) 8077/2Carcinoma in situ (CIS) of the cervix only. All other in situ cases are reportable.Basal and Squamous cell cancers (histology codes: 8000-8110) of the skin only (site code: C44._ only) are not reportable. Note: Basal cell and squamous cell cancers of any other site are reportable. Skin of labia (C51.0), vulva (C51.9), penis (C60.9) and scrotum (C63.2) are reportable.Patients seen only in consultation to provide a second opinion to confirm a diagnosis or a treatment plan.Patients in remission (there is no evidence of active disease) and not receiving prophylactic or adjuvant therapy.

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13Part II: Reporting RequirementsSection II.3:The NCCCR understands the scope of work required to meet these requirements for facilities. Therefore, physician offices are not being asked to report cases that meet either of the following two criteria: It is documented that the patient was previously seen as an inpatient or outpatient at a hospital or cancer treatment facility in North Carolina for the diagnosis or treatment for this tumor. It is documented that the patient later went to a hospital or cancer treatment facility in North Carolina and it is known that the other facility provided management for the diagnosis or treatment of this tumor.

Continuing with Section II.3: Cases NOT Required to be Reported.The NCCCR understands the scope of work required to meet these requirements for physician offices. Therefore, physician offices are not being asked to report cases that meet either of the following two criteria:

It is documented that the patient was previously seen as an inpatient or outpatient at a hospital with a cancer program accredited by the Commission on Cancer or cancer treatment facility in North Carolina for the diagnosis or treatment for this tumor.

It is documented that the patient later went to a hospital with a cancer program accredited by the Commission on Cancer or cancer treatment facility in North Carolina and it is known that the other facility provided management for the diagnosis or treatment of this tumor.

14Part II: Reporting RequirementsSection II.3 continued:Conditions of this situation:The other facilityMust be in North CarolinaCannot be another physicians office or treatment center not associated with a North Carolina facilityMust have provided cancer directed management of this tumorIf patient seen at another facility other than this tumor, or for reasons other than the direct management of this tumor, the case must be reported by the physician.If in doubt if a diagnosis meets reportability criteriaSubmit a reportReduces the need to report these as missed cases later

Continuing with Section II.3: Cases NOT Required to be Reported of the Electronic Reporting for Facilities training manual.In this situation, the other facility must be in North Carolina and cannot be another physicians office or treatment center not associated with a N.C. facility. Also, the other facility must have provided cancer-directed management of this tumor. If the patient was seen at another facility for a condition other than this tumor, or for reasons other than the direct management of this tumor, the case must be reported by the physician. If in doubt about whether the diagnosis meets the reportability criteria for physician offices, please submit a report. This will reduce the need to report these as a missed case at a later time.

15Part IIReporting Requirements Completed

This completes the training module for Part II: Reporting Requirements. Please close when you are ready and move to the next link to access the training module for Part III: Casefinding.

Thank you!16