Instructions and Reporting Requirements Module 8 Electronic Reporting For Facilities March 2013 North Carolina Central Cancer Registry State Center for

Instructions and Reporting Requirements Module 8 Electronic Reporting For Facilities March 2013 North Carolina Central Cancer Registry State Center for Health Statistics Division of Public Health Department of Health and Human Services 1908 Mail Service Center Raleigh, NC 27699-1908 http://www.schs.state.nc.us/units/ccr/ http://www.schs.state.nc.us/units/ccr/ North Carolina Central Cancer Registry

Part VIII Entering Information Into the New Case Abstract Form

Part VIII: Entering Information Into the New Case Abstract Form Before beginning a new report, read the following VERY IMPORTANT information A separate report must be completed and submitted for each independent primary tumor. o Example: If a patient is diagnosed with bladder cancer and a separate kidney cancer, a separate report must be submitted for each diagnosis. o Please complete the New Case Abstract form as ACCURATELY and COMPLETELY as possible. o Once the report is free of errors and is successfully submitted, it is considered as having been reported to the NCCCR.

Part VIII: Entering Information Into the New Case Abstract Form Before opening a new form and beginning data entry: o Make sure all information necessary for entering the case is available and on hand o Review the chart in its entirety o Make notes on a note pad or scrap paper if necessary to facilitate data entry o Confirm any information that is confusing or unclear with the physician. Session times out after 30 minutes if no activity takes place. o All information entered for the case (and not submitted) will be lost. o All information necessary for completing the case should be on hand prior to beginning data entry for that case.

Part VIII: Entering Information Into the New Case Abstract Form There is a Save function o Cases should be saved on a frequent basis. o Once the case is completely entered and all error messages are cleared, hospital staff must select Finish and Complete.. o If it is known that more information is needed or will be forthcoming, hold the case for a later time. Do not start data entry. o Cases started, but not completed, can be accessed at a later time. o Any information not saved will be lost and must be re- entered.

Part VIII: Entering Information Into the New Case Abstract Form Treatment information is very important: o Wait to enter report AFTER treatment plan is established Make sure START DATES for each treatment modality are known o It is not required for all treatment to be completed Treatment may continue for months or years o For patients who refuse treatment, do not receive treatment for any reason or when there is a decision not to treat (watchful waiting or active surveillance) Specifically record that decision of why there was not treatment in the treatment text area.

Part VIII: Entering Information Into the New Case Abstract Form Text is CRITICAL! o Over 100 additional data items will be coded by the NCCCR staff after the report is submitted. o This coding is highly dependent on the text you provide. o Provide as much information and detail as possible to describe the case. o It is critical to the accuracy and completeness of the final coding for the reported case.

Part VIII: Entering Information Into the New Case Abstract Form Screen Shots o A screen shot for each tab is provided in the following slides Each screen shot shows an example of what a completed screen would look like using a hypothetical prostate case o A table per screen shot is included with information on Each data field on the tab Any additional coding instructions for each tab o Pay particular attention to the format and content of the text areas used to describe the case In the screen shots, a red box [ ] indicates a required field Text boxes allow a limited number of characters

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.1: Entering Patient Personal Data on the Demographic Tab

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.1: Entering Patient Personal Data on the Demographic Tab - continued Data Field NameSpecial Coding Instructions Last Name* Special characters (,. / : ~ @ # & *) are not allowed in name fields. Enter the name without special characters. For example, enter OHARA for OHara. First Name* Middle SuffixLetters, numbers and periods only are allowed. SSN*The SSN can be entered with or without hyphens. Unknown should be avoided. 999-99-9999 is only allowed if the patient refused to provide his or her SSN. Sex/Gender*Unknown should be avoided. Birth Date*Date of birth may not be blank or unknown. Place of BirthCode 999 (unknown) if not specifically stated. Do not assume patient was born in the United States Race*Unknown should be avoided if at all possible. Race is very important in demographic studies. Request that this be dictated by the physician if not requested from the patient on the pre-visit paperwork. If patient is multiracial and one race is white, code the other race. Persons of Spanish or Hispanic origin may be of any race. Spanish OriginIf the patient is of Spanish or Hispanic origin, select the code that describes the specific origin. Use Code 0 (Non-Spanish) if there is no indication that patient is of Spanish/Hispanic Origin. Use Code 6 (Spanish/Hispanic NOS) if there is evidence (other than surname or maiden name) that the person is Hispanic, but cannot be assigned to the category in codes 15. Use Code 7 (Spanish Surname) when it is unknown if the patient is of Spanish/Hispanic Origin but the patient has a Spanish/Hispanic Surname. Industry and Occupation Record the occupation and industry where the patient worked for the majority of his or her lifetime. Example: Industry: Education, Occupation: Teacher If the usual occupation is not clear, enter the current occupation. If no information is known about the patients occupation, leave blank. Do not record Unknown. If the patient is a minor, or a student, or has never held an occupation (such as a homemaker), record Minor, Student or Never Worked.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued Special Coding Instructions Record the primary residence for the patient at the time of diagnosis. The address should be fully spelled out with standardized use of abbreviations and punctuation per U.S. Postal Service postal addressing standards. This is not necessarily the same as the patients current address. If it is known that the patient was living at a different address at the time of diagnosis, enter as much as is known and record UNKNOWN in the remaining address fields. For example, if all that is known is the city, then enter the city, state and zip and enter UNKNOWN in the street address. If no information regarding the address at diagnosis is known, then enter the current address. This is preferred over recording the address as entirely unknown. Patient Address at Diagnosis Should be the street address. PO Box is allowed but should only be used if the physical address is not known. City* State* Zip* If the last four digits of the zip code are known, enter them preceded by a hyphen. County* Use the drop down menu to make a selection. Type the county name to begin the search. Special Codes: 998 Residence not in North Carolina. The address at diagnosis was a state other than North Carolina. 999 - County is unknown. This is only allowed if the city is unknown.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab Cannot be unknown. Estimate as closely as possible. Pathology information is very important. Be very detailed. Use any available text field to provide additional pertinent information. Each procedure must include: Date, Procedure, Place, Findings. Text describing the primary site and histology (including behavior and grade) MUST be included here to validate the codes selected.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued Data Field NameSpecial Coding Instructions Date of Dx*Enter the first date it was stated the patient had this cancer. This may be a physicians statement of diagnosis or it may be based on the results of a diagnostic test or procedure. Date of Diagnosis cannot be blank or unknown and must be the earliest of all dates except for Birth Date. Estimate as closely as possible if an exact date is unknown. At least a valid year must be recorded. If there is absolutely no information to even estimate the year, record the same year as the patients first visit to your facility. Refer to Section VII.2: General Instructions for Using the Data Entry Screens for more information on how to complete the Date and Date Flag fields. Place of DxEnter the facility, treatment center, or physicians office that performed the first test or made the first statement that confirmed this diagnosis. If this was at your facility, then enter your facility name. If this is unknown, then record UNKNOWN.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued Data Field NameSpecial Coding Instructions Use free text in the following designated text areas to describe the results/findings of any diagnostic workup, staging workup, biopsies, and surgical procedures performed. For each procedure, record the date of the procedure, the procedure name, the place where the procedure took place, and the pertinent results/findings of the procedure. This should include pertinent negative findings in addition to positive findings. Example: 10/19/2011, CT ABD/PELVIS, UROL ASSOC. ENLARGED PROSTATE. NO ADENOPATHY. NO MET DZ SEEN Physical Exam Include age, rage and sex of patient Include pertinent information from the H&P including the evaluation of the location and extent of the tumor and other symptoms that may suggest further disease spread. X-rays/Scans Include the results of any imaging or ultrasound tests performed to evaluate the tumor Scopes This includes endoscopies, etc. Lab Values In addition to the lab test and result, state whether the test was considered to be elevated, abnormal or within normal limits Only lab tests that are diagnostic or prognostic for that primary site need to be summarized. Examples include CA-125, CEA, PSA, etc. Routine blood tests such as CBC do not need to be included

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued Data Field NameSpecial Coding Instructions Use free text in the following designated text areas to describe the results/findings of any diagnostic workup, staging workup, biopsies, and surgical procedures performed. For each procedure, record the date of the procedure, the procedure name, the place where the procedure took place, and the pertinent results/findings of the procedure. This should include pertinent negative findings in addition to positive findings. Example: 10/19/2011, CT ABD/PELVIS, UROL ASSOC. ENLARGED PROSTATE. NO ADENOPATHY. NO MET DZ SEEN Path/Autopsy* This section is very important. Include the findings from all cytologic (FNA, brushings, etc.) and histologic (biopsy, surgical resection, etc.) examinations performed. Clearly separate each procedure and findings with separate statements. In addition to the basic text elements such as date, procedure, place and findings, include the status of the following: Final diagnosis as written on the report Location of the tumor (primary site and laterality) Histology (EXACTLY as stated on the report) Behavior (invasive or in situ) Grade including site specific grade such as Gleason Tumor Size Tumor extension into other surrounding tissues Surgical Margins # Lymph Nodes removed and positive Examination of metastatic tissues Ancillary studies such as tumor markers Relevant findings from the gross examination including aids in identifying the primary site and extent of disease

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Tumor Data on the Dx/Staging Tab - continued Data Field NameSpecial Coding Instructions Site* Select the organ/tissue in which the primary tumor arose/originated. If the exact site cannot be identified, but it is known to have originated in the breast, select code C50.9 breast, NOS If the exact site cannot be identified, but it is known to have originated in the skin, select code C44.9 Skin, NOS Codes ending in.9 are used when there was a single tumor that overlapped the boundaries of two or more sub-sites and the point of origin could not be determined (Bladder, NOS C67.9) or there is not a choice of sub-sites (Prostate C61.9) Dx Confirmation Select the code that describes the best diagnostic method used to confirm the cancer being reported. The coded are listed in priority order. Code 1 has the highest priority. If the presence of cancer is confirmed with multiple diagnostic methods, select the code with the lower numeric value. Code 1 (positive histology) includes: Tissue specimens from biopsy, frozen section, surgery, autopsy or D&C, aspiration or biopsy of bone marrow. Code 2 (positive cytology) includes: Cytologic examination of cells such as sputum smears, bronchial brushings, bronchial washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, peritoneal fluid, pleural fluid, urinary sediment, cervical smears and vaginal smears, or from paraffin block specimens from concentrated spinal, pleural, or peritoneal fluid.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Tumor Data on the Dx/Staging Tab - continued Data Field NameSpecial Coding Instructions Laterality* If the primary site is a bilateral organ, the side in which the tumor originated (laterality) must be specific. We have provided a few of The following are the paired organ sites below. C34.1 C34.9 Lung C44.1 Skin of eyelid C44.2 Skin of external ear C50.0 c50.9 Breast C62.0 C62.9 Testis C63.0 Epididymis C63.1 Spermatic cord C64.9 Kidney, NOS Use code 0 for all other non-paired organs Use code 4 if the following conditions are met (e.g. bilateral Wilms tumors): There was a bilateral involvement at time of diagnosis, It contained the same histology, And it is considered a single primary.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Tumor Data on the Dx/Staging Tab - continued Data Field NameSpecial Coding Instructions Use text in the following designated text areas to describe the facts about the stage (extent of disease) of the cancer at the time of diagnosis. The Staging text areas may not be left blank. This information will be used by the NCCCR staff to code 42 data items related to the stage of the tumor. Be as specific as possible, even if it means repeating information from the previous tab. Include descriptive words such as consistent with, probably, suggests, with features of, abutting, extending to, etc. Enter NONE to indicate there was not information available from the workup to evaluate that particular extent of disease (extension, lymph nodes, or mets). Summarize the extent of the disease using all of the workup performed (clinical and pathologic). This includes the findings from the physical exam, imaging, scopes, lab work, biopsies, surgeries, etc. For these three text areas, the date or place of the procedure does not need to be repeated unless it is needed to clarify the information. Extension* From all of the workup performed, summarize the extent of the primary tumor. Summarize the following: Tumor size Involvement with the primary organ Extension into surrounding tissues. Mets at Dx* From all of the workup performed, summarize any evidence of metastatic disease present at the time of diagnosis. It is very important to differentiate metastatic disease present at the time of diagnosis and metastatic disease discovered after initial diagnosis and treatment. Lymph Node involvement* From all of the workup performed, summarize any evidence of regional lymph node involvement present at the time of diagnosis. Summarize the following: Name of the lymph node chain involved Number of lymph nodes involved Number of lymph nodes examined Any documentation that the lymph nodes were evaluated and were negative.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Tumor Data on the New Case Abstract Form - continued Data Field NameSpecial Coding Instructions RemarksDocument ALL known previous primaries including site, laterality, histology & diagnosis date if available. Family History. Smoking History. Information that explains unusual circumstances, use of estimated dates, referral information, etc.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.3: Entering Facility Data on the Hospital Tab Include the NPI number for each facility. Include the NPI number for each physician. First date the patient was seen at your facility with cancer. Type of facility Name and type of Insurance

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.3: Entering Facility Data on the Hospital Tab - continued Data Field NameSpecial Coding Instructions Facility information must be entered by the user each time the user logs on to the Eureka system, Facility information only needs to be entered for first case entered. Facility #* Select the Facility Identification Number assigned to the facility in which you are reporting cases. This was the number assigned to your facility when you requested a Eureka account. If the patient was seen at another hospital, treatment center or physicians office for the management of this tumor, select the appropriate code for Referred From or Referred To from the drop down menu. If the facility or physicians office for the Referred From of Referred To fields was not an available option in the associated selection boxes, leave the default o 0000000000 and record the name of the facility in the Remarks text section. There are several special codes for when the exact facility name is not known or the patient was referred out of state. Search the menu options carefully before making a final selection. Referred From Patient seen elsewhere for management of this tumor before visit at your office. If the patient was not referred, leave the default of 0000000000. Referred To Patient seen elsewhere for the management of this tumor after visit at your office. If the patient was not referred, leave the default of 0000000000. Attending MD Enter the name of the physician at your office caring for the patient. Surgeon Enter the name of the physician who performed the cancer-directed surgery for the treatment of this tumor.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.3: Entering Facility Data on the Hospital Tab - continued Data Field NameSpecial Coding Instructions NPI Numbers For each facility and physician recorded above, enter their NPI number assigned by CMS. This must be entered as a 10-digit number. To obtain NPI numbers for your facility and other local providers start with the billing department. It may be helpful to create a list of numbers for physicians and hospitals commonly participating in the care of your patients to have on hand when entering cases. For NPI numbers not available by the billing department, use the Centers for Medicare and Medicaid Services (CMS) website. The Data Dissemination page provides further links to access a searchable database where you can search for individual providers. NPI Registry (searchable data base): www.cms.hhs.gov/National/ProvidentStand/www.cms.hhs.gov/National/ProvidentStand/ Click on Data Dissemination

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.2: Entering Facility Data on the Hospital Tab - continued Data Field NameSpecial Coding Instructions Medical Rec #Letters, numbers and hyphens only are allowed. Insurance (Pay Source &Text) Admission Date (Date 1st seen with Cancer) This is the first date the patient was seen at your facility with a diagnosis of cancer. If the patient is diagnosed as a result of testing performed during the visit, the date will be the date of this visit. This should not be blank or unknown. Type of AdmissionSelect the type of admission (inpatient, outpatient, etc.)

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Treatment Data on the New Case Abstract Form Each procedure must include: Date, Procedure Name and Place (where the procedure was done). Findings, if summarized on the previous tab, do not need to be repeated here. If the patient did not receive that particular type of treatment, select the flag code of 11.

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Treatment Data on the New Case Abstract Form - continued Data Field NameSpecial Coding Instructions Surgery Date, Flag, Text Record the first date caner-directed surgery was performed as part of the first course of therapy. If multiple surgical procedures were performed, record the date of the first surgical procedure. Do not include biopsy dates unless the biopsy removed the entire tumor. In the text area, describe as much as is known about the following: Procedure date Place/facility performed It is important to delineate the specific details for each procedure performed. While biopsies are not included in the Surgery Date, a summary of any biopsies should be included in the Surgery Text. Chemo Date, Flag, Text For each of these treatment types, record the first start date for that treatment delivered to the patient as part of the first course of therapy. If multiple drugs were given, record the date the first drug was taken. For each of the treatment types, describe as much as is known about the following: Start and end dates Place/facility given Name of each drug/treatment given Note: Other Treatment includes any treatment that does not qualify as Radiation, Surgery, Chemo, Hormones, or Immunotherapy. Other treatment also includes experimental and non-traditional treatment. Hormone Date, Flag, Text Immunotherapy Date, Flag, Text Other Treatment Date, Flag, Text

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Treatment Data on the New Case Abstract Form - continued Data Field NameSpecial Coding Instructions Use the following date fields to record the start date for each type of treatment received for this tumor. If that particular treatment was not given, leave the date blank and select code 11 as the corresponding date flag. Refer to Section VII.2: General Instruction for Using the Date Entry Screens for more information on how to complete the Date and Date Flag fields. Use free text in the corresponding text area to describe that particular first course of treatment. See the definition of first course treatment below. These text areas may be left blank if that particular treatment was not given. No therapy is a treatment option that occurs if the patient refuses treatment, the family or guardian refuses treatment, the patient dies before treatment starts, or the physician recommends no treatment to be given (patient is too sick, watchful waiting, etc.). If no treatment is given, record the reason for no treatment in any one of the following text areas. Radiation Date, Flag, Text Record the start date for the radiation therapy delivered to the patient as part of the first course of therapy. In the text area, describe as much as is known about the following: Start and end dates Place/facility given Area of body treated Modality (type, energy) Dose (amount of radiation)

Part VIII: Entering Information Into the New Case Abstract Form Section VIII.4: Entering Treatment Data on the Tumor Data Tab continued Definition of First Course of Treatment First course of treatment includes all methods of treatment recorded in the treatment plan and administered to the patient at the time of the initial diagnosis and before disease progression or recurrence. A treatment plan describes the type(s) of therapies intended to modify or control the malignancy. The documentation confirming a treatment plan may be found in several different sources; for example, medical or clinic records, consultation reports, and outpatient records. All therapies specified in the physician(s) treatment plan are a part of the first course of treatment if they are actually administered to the patient. An established protocol or accepted management guidelines for the disease can be considered a treatment plan in the absence of other written documentation. If there is no treatment plan, established protocol, or management guidelines, and consultation with a physician advisor is not possible, only record treatment that began within four months of the date of initial diagnosis.

Part VIII: Entering Information Into the New Case Abstract Form Part VIII: Entering Information Into the New Case Abstract Form Section VIII.5: Entering Information on the Follow-up Tab continued Enter the last date the patient was seen or the date of death. Select the option which indicates the condition of the cancer at the time of the visit.

Part VIII: Entering Information Into the New Case Abstract Form Part VIII: Entering Information Into the New Case Abstract Form Section VIII.5: Entering Information on the Follow-up Tab continued Data Field NameSpecial Coding Instructions Vital Status The Vital Status should remain Alive unless there is documentation of the patients death prior to reporting the case. Follow-up Date (Date of Last Appt.) This is the last date the patient was seen at your facility, regardless of the reason for the visit or the disease status. This should not be blank or unknown. *If Date of Death is entered, it must be the latest date entered in the record. State and Place - Country of Death Enter the state and country where the patient died. Tumor StatusAt the time of the last visit to your facility, indicate whether the patient had evidence of this disease or was considered disease free.

Part VIII Entering Information Into the New Case Abstract Form Completed

Documents

Instructions and Reporting Requirements Module 8 Electronic Reporting For Facilities March 2013 North Carolina Central Cancer Registry State Center for