Electronic Reporting for Urology Physician Practices

Instructions and Reporting RequirementsModule 8Electronic ReportingForFacilitiesMarch 2013

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

Welcome back!

Im Ashanti Scott-Prince and I will be your narrator for this training session. The North Carolina Central Cancer Registry has produced this training, along with the previous trainings, to guide you on how to use the New Case Abstract form for facilities.

1Part VIII Entering Information Into the New Case Abstract Form

You are now entering Training Module 8 which will review Part VIII: Entering Information Into the New Case Abstract Form as identified in the Electronic Reporting for Facilities training manual.

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).We will now resume the training.2Part VIII: Entering Information Into the New Case Abstract FormBefore beginning a new report, read the following VERY IMPORTANT informationA separate report must be completed and submitted for each independent 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.Please complete the New Case Abstract 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.

PART VIII: ENTERING INFORMATION INTO THE NEW CASE ABSTRACT FORM Before beginning a new report, read the VERY IMPORTANT information on this and the following slides very carefully: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.

Please complete the New Case Abstract 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.

3Part VIII: Entering Information Into the New Case Abstract FormBefore opening a new form and beginning data entry:Make sure all information necessary for entering the case is available and on handReview the chart in its entiretyMake notes on a note pad or scrap paper if necessary to facilitate data entryConfirm any information that is confusing or unclear with the physician.Session times out after 30 minutes if no activity takes place.All information entered for the case (and not submitted) will be lost. All information necessary for completing the case should be on hand prior to beginning data entry for that case.

Before opening a new form and beginning data entry: Make sure all information necessary for entering the case is available and on hand Review the chart in its entiretyMake notes on a notepad or scrap paper if necessary to facilitate data entryConfirm any information that is confusing or unclear with the physicianSession times out after 30 minutes if no activity takes place. (Take special note of this please!) All information entered for the case (and not submitted) will be lost. All information necessary for completing the case should be on hand prior to beginning data entry for that case.

4Part VIII: Entering Information Into the New Case Abstract FormThere is a Save functionCases should be saved on a frequent basis. Once the case is completely entered and all error messages are cleared, hospital staff must select Finish and Complete. .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.Cases started, but not completed, can be accessed at a later time.Any information not saved will be lost and must be re-entered.

Another very important function of the screen to note is that there is a Save function.

Once the case is completely entered and all error messages are cleared, hospital staff must select Finish and Complete.

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.

Cases started, but not completed, can be accessed at a later time.

Any information not saved will be lost and must be re-entered.

5Part VIII: Entering Information Into the New Case Abstract FormTreatment information is very important:Wait to enter report AFTER treatment plan is establishedMake sure START DATES for each treatment modality are knownIt is not required for all treatment to be completedTreatment may continue for months or yearsFor 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.

Treatment information is very important:

Please wait to enter the report until after the treatment plan is established and the start dates for each treatment modality are known.

It is not required that all treatment be completed as treatment may continue for months or years.

For patients that 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 no treatment with the date of the decision in the treatment text area.

6Part VIII: Entering Information Into the New Case Abstract FormText is CRITICAL!Over 100 additional data items will be coded by the NCCCR staff after the report is submitted.This coding is highly dependent on the text you provide.Provide as much information and detail as possible to describe the case.It is critical to the accuracy and completeness of the final coding for the reported case.

Again, Text is CRITICAL!

Over 100 additional data items will be coded by the NCCCR staff after the report is submitted.

This coding is highly dependent on the text provided.

Provide as much information and detail as possible to describe the case, as this is critical to the accuracy and completeness of the final coding for the reported case.7Part VIII: Entering Information Into the New Case Abstract FormScreen ShotsA 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 caseA table per screen shot is included with information onEach data field on the tabAny additional coding instructions for each tabPay particular attention to the format and content of the text areas used to describe the caseIn the screen shots, a red box [ ] indicates a required fieldText boxes allow a limited number of characters

A screen shot for each tab is provided in the next slides along with a table that lists each data field on that tab and any additional coding instructions. Remember you can refer to these in the manual as well.

Each screen shot shows the required fields in a red box .

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. 8Part VIII: Entering Information Into the New Case Abstract FormSection VIII.1: Entering Patient Personal Data on the Demographic Tab

This screen shot shows an example of what a completed Demographic Tab screen would look like. The red box indicated the required fields in the Demographic Tab.

9Part VIII: Entering Information Into the New Case Abstract FormSection VIII.1: Entering Patient Personal Data on the Demographic Tab - continuedData Field NameSpecial Coding InstructionsLast Name* Special characters (, . / : ~ @ # & *) are not allowed in name fields. Enter the name without special characters. For example, enter OHARA for OHara.First Name* MiddleSuffixLetters, 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 StatesRace* 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 andOccupationRecord the occupation and industry where the patient worked for the majority of his or her lifetime.Example: Industry: Education, Occupation: TeacherIf 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.

See section VIII.1: Entering Patient Personal Data on the Demographic Tab in the manual to view this table with the following Demographic screen fields and their explanations. I will review them one by one now.

Last Name* and First Name* are required fields. Please use the Middle field for middle name or initial if you have it.Special characters (, . / : ~ @ # & *) are not allowed in name fields. Enter the name without special characters. For example, enter OHARA for OHara.

SuffixLetters, numbers and periods only are allowed.

Social Security Number (SSN)* is a required field.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* is a required field.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* is a required fieldUnknown 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 OccupationRecord the occupation and industry where the patient worked for the majority of his or her lifetime.Example: Industry: Education, Occupation: TeacherIf 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.

10Part VIII: Entering Information Into the New Case Abstract FormSection VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continuedSpecial Coding InstructionsRecord 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 DiagnosisShould 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.

Here we continue the review of the fields for the Dx/Staging tab. This is again, to provide special notes about the fields in the screen.

The focus for this slide is the patients address or primary residence. Please ensure you follow these guidelines.

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. A P.O. Box address is allowed but should only be used if the physical address is not known.

City, State, Zip Code and County are all required fields0.If the last four digits of the zip code are known, enter them preceded by a hyphen.When entering the county information,Use the drop down menu to make a selection. Type the county name to begin the search. Special Codes are: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.

11Part VIII: Entering Information Into the New Case Abstract FormSection 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.

Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab moves into information about the Dx/Staging screen.

This screen shot can be found in the manual in Section VIII:2. Here we show the Dx/Staging screen with hypothetical patient information so you can, again, see what the screen would look like completed.

The yellow text/comment boxes point out important tips you need to pay particular attention to. They are as follows.

Date of Dx field: The date of diagnosis cannot be unknown. Estimate as closely as possible.

Physical Exam text box: Each procedure must include Date, Procedure, Place and Findings. Do not forget Age, Sex and Race!

Staging text box: Use any available text field to provide additional pertinent information.

Path/Autopsy text box: Pathology information is very important. Be very detailed. Text describing the primary site and histology (including behavior and grade) MUST be included here to validate the codes selected above.

12Part VIII: Entering Information Into the New Case Abstract FormSection VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continuedData Field NameSpecial Coding InstructionsDate 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.

Here we begin a review of the fields for the Dx/Staging tab on the screen.

Date of Dx* - again this is a required fieldEnter 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.

13Part VIII: Entering Information Into the New Case Abstract FormSection VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continuedData Field NameSpecial Coding InstructionsUse 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 SEENPhysical ExamInclude age, rage and sex of patientInclude 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/ScansInclude the results of any imaging or ultrasound tests performed to evaluate the tumorScopesThis includes endoscopies, etc.Lab ValuesIn addition to the lab test and result, state whether the test was considered to be elevated, abnormal or within normal limitsOnly 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

Continuing with more important notes about the fields in the Dx/Staging tab.

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 ExamInclude age, race and sex of patient. Include pertinent information from the History & Physical (H&P) including the evaluation of the location and extent of the tumor and other symptoms that may suggest further disease spread.

X-Rays/ScansInclude the results of any imaging or ultrasound tests performed to evaluate the tumor.

ScopesThis includes endoscopies, etc.

Lab ValuesIn 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. Routing blood tests such as CBC do not need to be included.

14Part VIII: Entering Information Into the New Case Abstract FormSection VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continuedData Field NameSpecial Coding InstructionsUse 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 reportLocation 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 GleasonTumor SizeTumor extension into other surrounding tissuesSurgical Margins# Lymph Nodes removed and positiveExamination of metastatic tissuesAncillary studies such as tumor markersRelevant findings from the gross examination including aids in identifying the primary site and extent of disease

More important notes about the fields on the Dx/Staging tab:

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 reportLocation 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 GleasonTumor sizeTumor extension into other surrounding tissuesSurgical marginsNumber of lymph nodes removed and positiveExamination of metastatic tissuesAncillary studies such as tumor markersRelevant findings from the gross examination including aids in identifying the primary site and extent of disease

15Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Tumor Data on the Dx/Staging Tab - continuedData Field NameSpecial Coding InstructionsSite*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, NOSIf the exact site cannot be identified, but it is known to have originated in the skin, select code C44.9 Skin, NOSCodes 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 ConfirmationSelect 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.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.

Here we continue the review of the information shown in the Tumor Data table. The table is meant to provide special coding instructions for the fields in the Dx/Staging Tab screen. We will review the fields starting at the top with Site*. You can refer back to the screen shot slide to see the fields described in the table.

Site* - a required fieldSelect 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 .8 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. For example, a bladder tumor that involves the lateral and anterior walls (select code C67.8 Overlapping lesion of bladder).Codes ending in .9 are used when the sub-site could not be determined (example: Bladder, NOS C67.9) or there is not a choice of sub-sites (example: Prostate C61.9).

Dx Confirmation Select the code that describes the best diagnostic method used to confirm the cancer being reported.The codes 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.

16Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Tumor Data on the Dx/Staging Tab - continuedData Field NameSpecial Coding InstructionsLaterality*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 LungC44.1 Skin of eyelidC44.2 Skin of external earC50.0 c50.9 BreastC62.0 C62.9 TestisC63.0 EpididymisC63.1 Spermatic cordC64.9 Kidney, NOSUse code 0 for all other non-paired organsUse 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.

Here we continue the review of the Tumor Data table. The table is meant to provide special coding instructions for the fields in the Dx/Staging Tab. You can refer back to the screen shot slide to see the fields described in the table.

Laterality* - a required fieldIf the primary site is a bilateral organ, the side in which the tumor originated (laterality) must be specified. The following are a few of the paired organ sites.C34.1 C34.9 LungC44.1 Skin of eyelidC44.2 Skin of external earC50.0 c50.9 BreastC62.0 C62.9 TestisC63.0 EpididymisC63.1 Spermatic cordC64.9 Kidney, NOSUse code 0 for all other non-paired organsUse code 4 if the following conditions are met (e.g., bilateral Wilms tumors):there was bilateral involvement at time of diagnosis, it contained the same histology, andit is considered a single primary.

17Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Tumor Data on the Dx/Staging Tab - continuedData Field NameSpecial Coding InstructionsUse 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 sizeInvolvement with the primary organExtension 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 involvedNumber of lymph nodes involvedNumber of lymph nodes examinedAny documentation that the lymph nodes were evaluated and were negative.

Again, we continue a review of the information on the Tumor Data table created to provide special coding instructions for the fields in the Dx/Staging tab. You can refer back to the screen shot slide to see the fields described in the table.

Use free 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. These 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 no information available from the workup to evaluate that particular extent of disease (extension, Mets at Dx, or lymph node involvement).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* - this is a required fieldFrom all of the workup performed, summarize the extent of the primary tumor. Summarize the following:Tumor sizeInvolvement within the primary organExtension into surrounding tissues.

Mets at Dx* - this is a required fieldFrom 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* - this is a required fieldFrom 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 involvedNumber of lymph nodes involvedNumber of lymph nodes examinedAny documentation that the lymph nodes were evaluated and were negative.

18Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Tumor Data on the New Case Abstract Form- continuedData Field NameSpecial Coding InstructionsRemarksDocument 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.

This is the final slide reviewing the tumor data on the New Case Abstract form. Again, this table was created to provide special coding instructions for the fields on the New Case Abstract form. You can refer back to the screen shot slide to see the fields described in the table.

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, etc.

In addition, use this area to provide the following information:Record the date of diagnosis and primary site for any other primaries this patient has had in his or her lifetime, regardless if it is being reported by your facility.If the facility for the Referred From or Referred To fields was not an available option in the associated selection boxes, record the name of the facility here. For example, Referred from Any Town Hospital.Use this text area to provide any additional pertinent information about this case.

19Part VIII: Entering Information Into the New Case Abstract FormSection 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 facilityName and type of Insurance

We have now come to Section VIII.3: Entering Facility Data on the Hospital Tab. Here we begin a review of the screen shot in the manual which provides special notes about the fields in the red boxes in the Hospital Tab screen where you will enter facility data.

The screen shot was created with a hypothetical case so you can see what it should look like when you have completed the data entry.

Please note the required fields are again indicated by the red boxes.

The required fields on this screen are:Hospital and NPI numberHospital Referred From/ToType of FacilityPay Source (type of insurance)Payer Text (name of insurance)Medical Record NumberFirst Admission (date arrived at the facility with cancer)Physicians and NPI number

20Part VIII: Entering Information Into the New Case Abstract FormSection VIII.3: Entering Facility Data on the Hospital Tab- continuedData Field NameSpecial Coding InstructionsFacility 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 FromPatient seen elsewhere for management of this tumor before visit at your office. If the patient was not referred, leave the default of 0000000000.Referred ToPatient 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 MDEnter the name of the physician at your office caring for the patient.SurgeonEnter the name of the physician who performed the cancer-directed surgery for the treatment of this tumor.

Here we begin a review of the table in Section VIII:3: Entering Facility Data on the Hospital Tab. The table is meant to provide special coding instructions for the fields in the Hospital Tab screen.

Facility information must be entered by the user each time the user logs on to the Eureka system.

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 or Referred To fields was not an available option in the associated selection boxes, leave the default of 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 FromPatient seen elsewhere for management of this tumor before visit at your facility. If the patient was not referred, leave the default of 0000000000.

Referred ToPatient seen elsewhere for the management of this tumor after visit at your facility. If the patient was not referred, leave the default of 0000000000.

Attending MDEnter the name of the physician at your facility caring for the patient.

SurgeonEnter the name of the physician who performed the cancer-directed surgery for the treatment of this tumor.

21Part VIII: Entering Information Into the New Case Abstract FormSection VIII.3: Entering Facility Data on the Hospital Tab - continuedData Field NameSpecial Coding InstructionsNPI NumbersFor 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/Click on Data Dissemination

Here we continue the review of the table. The table is meant to provide special coding instructions for the fields in the Hospital Tab screen.

NPI NumbersFor 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 database): www.cms.hhs.gov/NationalProvIdentStand/Click on "Data Dissemination."

22Part VIII: Entering Information Into the New Case Abstract FormSection VIII.2: Entering Facility Data on the Hospital Tab- continuedData Field NameSpecial Coding InstructionsMedical 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.)

Continuing the review of the table. The table is meant to provide special coding instructions for the fields in the Hospital Tab screen.

Medical Rec # Letters, numbers and hyphens only are allowed.

Insurance (Pay Source & Text)

Admission Date (Date first 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.)

23Part VIII: Entering Information Into the New Case Abstract FormSection 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.

This begins Section VIII.4: Entering Treatment Data on the New Case Abstract form

Here we review the screen shot of the bottom section of the New Case Abstract form . The screen shot is meant to provide an example of what the treatment area on the New Case Abstract form would look like when completed. The required fields are marked with a red box. We have also added yellow comment boxes to bring special attention important information regarding the fields.

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.24Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Treatment Data on the New Case Abstract Form - continuedData Field NameSpecial Coding InstructionsSurgery Date, Flag, TextRecord 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 datePlace/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, TextFor 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 datesPlace/facility givenName of each drug/treatment givenNote: 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.HormoneDate, Flag, TextImmunotherapyDate, Flag, TextOther TreatmentDate, Flag, Text

Yes, this is a lot of information, but very important to the correct data submission for the cases you are reporting.

Here we continue on with the review of the table providing special coding instructions for the fields on the New Case Abstract form. You can refer back to the screen shot slide to see the fields described in the table.

Surgery Date, Flag, TextRecord the first date cancer-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 datePlace/facility performedName of procedure including lymph node resectionsIt 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, Hormone, Immunotherapy or Other Date, Flag, TextFor 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 datesPlace/facility givenName of each drug/treatment givenNote: 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.

25Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Treatment Data on the New Case Abstract Form - continuedData Field NameSpecial Coding InstructionsUse 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, TextRecord 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 datesPlace/facility givenArea of body treatedModality (type, energy)Dose (amount of radiation)

Continuing on with the review of the table providing special coding instructions for the fields on the New Case Abstract form. You can refer back to the screen shot slide to see the fields described in the table.

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 Instructions for Using the Data 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 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, TextRecord the start date for the radiation therapy delivered to the patient as part of the first course of treatment.In the text area, describe as much as is known about the following:Start and end datesPlace/facility givenArea of body treatedModality (type, energy)Dose (amount of radiation)

26Part VIII: Entering Information Into the New Case Abstract FormSection VIII.4: Entering Treatment Data on the Tumor Data Tab continued

Definition of First Course of TreatmentFirst 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.

Finally, we mentioned the Definition of First Course of Treatment earlier and want to be sure to bring this definition to your attention. Please see the manual if you are using the manual to follow along with this training.

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 or types 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.

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Part VIII: Entering Information Into the New Case Abstract FormSection 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.

This begins Section VIII.5: Entering Information into the Follow-up Tab. The table is meant to provide special coding instructions for the fields in red boxes in the Follow-up Tab screen.

Here we review the screen shot of the Follow-up tab. The screen shot is meant to provide an example of what the Follow-up Tab screen would look like when completed. We have also added a few yellow comment boxes to bring special attention to these fields.

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Part VIII: Entering Information Into the New Case Abstract FormSection VIII.5: Entering Information on the Follow-up Tab continued

Data Field NameSpecial Coding InstructionsVital StatusThe 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 DeathEnter 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.

We will continue with Section VIII.5: Entering Information into the Follow-up Tab. The table is meant to provide special coding instructions for the fields in the Follow-up tab screen.

Vital StatusThe 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 abbreviation and select the 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.

29Part VIIIEntering Information Into the New Case Abstract FormCompleted

This completes the training module for Part VIII: Entering Information Into the New Case Abstract Form. Please close when you are ready and move to the next link to access the training module for Part IX: Finalizing and Submitting the New Case Abstract Form in the Electronic Reporting for Facilities training manual.

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