Cancer Registry and Coding: The Hidden Relationship
Cancer registry data collection starts with a process known as case-finding or case ascertainment, and it is exactly that, finding cases that must be included in a reporting facility’s cancer registry. Each year the standard setters: Commission on Cancer, SEER, North American Association of Central Cancer Registries, and State Central Registries determine a list of reportable cases. These lists are based on confirmed malignancy, history of malignancy, screening, and/or treatment for malignancy. There are also numerous benign, hematopoietic and lymphoid reportable diseases included in the list.
All facilities are required to have a process for identifying, collecting, and reporting specific neoplasms. The process should include concurrent monitoring of:
• Disease indices from the facility and all associated medical practices
• Pathology, cytology, and autopsy reports
• Log sheets and other registration reports from treatment clinics or departments that have separate billing/coding processes such as medical oncology, infusion, radiation oncology, and surgical centers.
Historically, Cancer Registries have had to be innovative in order to perform proper case-finding depending on their environment. In addition to the gold standard sources which are the Disease Index and pathology reports, a Cancer Registrar would collect other “source documents” which translated into mounds of paper. These included daily Admission, Discharge and Transfer (ADT) report, weekly billing reports, medical oncology and/or radiation oncology log sheets, imaging logs and reports, outpatient surgical units, and autopsy reports. After data collection was complete, the Cancer Registrar would manually cross-reference the paper reports with the cancer registry database to determine if a patient was already in the database (and only required updates) or if the case was entirely new.
Although the electronic health record (EHR) has reduced the need for manual data gathering, some cancer registries still use paper methodologies to perform case-finding as they feel it is a necessary fail-safe. Although this approach may have validity, it is inefficient as cost-benefit analyses have proven. Current best practices include electronic import of the disease indices from all departments with billable services and pathology reports with a reportable diagnosis.
The ongoing challenge is to capture cases that have had a biopsy or surgical procedure with a negative outcome after a procedure that had previously generated cancerous tissue. The final procedure would not generate pathologically demonstrating cancer but is required to complete the treatment portion of the database for the individual patient. Hospitals that implement best practices will utilize information found during case-finding to update cases with subsequent treatment and additional follow-up information such as date and type of the first recurrence, disease status, and vital status, which are required data items.
Disease indices and positive pathologic outcomes are considered the gold standard for case finding because of the integrity of the coded data that informs them. Accurately coded data paints the true clinical picture of the patient and drives the work of Cancer Registries nationwide. Without it, patients are lost to Cancer Registries as well as the benefits of cancer control and epidemiological research, public health program planning, and patient care improvement. Although documentation in the patient’s record can be unclear or ambiguous at times, it is incumbent upon the coding professional to seek clarification when necessary. Coded data has a long and influential life span, and its importance goes beyond today’s revenue. It is important to remember the micro and macro purposes of coded data, including quality outcomes, risk adjustment, predictive analysis, population health, medical research, fiscal integrity, and institutional longevity. Accurately coded data improves patient care and ultimately saves lives.
A disease index should identify all ICD-10 codes that indicate a patient has a reportable diagnosis, a history, and/or screening diagnosis as identified annually by the State Cancer Registry and accrediting bodies. In many cases, multiple disease indices will be required depending on the facility’s affiliations and billing practices for specific physicians, procedures, and office visits. Ideally, the disease index would be the only “tool” required for case finding; however, due to the complexities of billing practices and individual facility practices, pathology reports must also be monitored to ensure at a minimum all-new pathologically diagnosed cases are captured in a timely manner. At the November 20-21, 2019 Commission on Cancer Educational Summit, an announcement was made that in the very near future, most likely by 2021-concurrent abstracting will be required to comply with the Rapid Cancer Reporting System (RCRS). A timely, efficient and comprehensive case-finding process will be required as compliance with this process will require monthly submission of all newly identified cases as well as monthly updates for all cases that remain incomplete or require an update of surveillance information in the cancer registry database. The power of ICD-10, harnessed by accuracy and specificity, plays a vital role in winning the War on Cancer.