Working on coding

More and more State Central Registries are requesting additional information, or rejecting abstracts submitted by reporters.  If the text is incomplete, inaccurate or illegible, the abstract is in question and is considered unusable until the data can be verified. This is a considerable consumer of human and technical resources for both the State Registry and the reporter that has to research and re-abstract the record.

More and more State Central Registries are requesting additional information, or rejecting abstracts submitted by reporters.  If the text is incomplete, inaccurate or illegible, the abstract is in question and is considered unusable until the data can be verified. This is a considerable consumer of human and technical resources for both the State Registry and the reporter that has to research and re-abstract the record.

All State Cancer Registries require text to support all codes in an abstract. Per the North American Association of Central Registries (NAACCR) standards: Text should be Included in the registry’s data set and transmitted along with codes when tumor records are shared with other registries.

Review of the SEER Program Coding and Staging Manual revealed; for each and every instruction for coding, some version of the following instruction is included: “Use the associated text field to document.”

Codes and text should provide the same information on the patient and the patient’s disease. Use of either data set should result in the same outcome. Documentation should only include information that can be validated and supported from documentation in a medical record or other valid documented resource.  Never make assumptions based on input from a Cancer Conference or a Treatment Plan. All documentation must be confirmed and supported appropriately by identifying the source.

Correct spelling and use of only standardized abbreviations is important as cancer registry abstracts are now used as a source for Survivorship Care Guidelines, research verification and quality control purposes. Text must be concise and pertinent to the specially coded areas of an abstract.

The purpose of text is:

  • To ensure that codes are correctly applied.
  • To include but not limited to validation of unusual occurrences such as a unique presentation of a specific histology, unusual primary site, metastatic site or perhaps an age and primary site discrepancy.
  • Edit check verification.
  • To facilitate recoding audits.
  • Facilitate researchers use.
  • Support audits of historical data.

Text should always document:

  • Resource type (consult note, op note, treatment summary, newspaper obituary, SS Death Index, CTR from another facility to include name, date, and facility).
  • Date of event.
  • Place of event (name of facility or MD office).
  • Type of event (procedure, lab, imaging, H&P, consult, treatment, etc.).
  • Who performed the service (name of physician, ordering physician, etc.).
  • Summary of event.

The term “defensive abstracting” is often used in webinars and other training sessions to describe why to include text properly. If coding in an abstract is in question the only way to defend or justify the code is via the text. In other words, if you do not want to be questioned about the validity or quality of your coding, include text to clearly justify the rationale for the code.

Random examples as provided in the current SEER Manual:

  • Assign the NOS code for the body system when there are two or more possible primary sites documented and all are within the same system. Example: Two possible sites are documented in the GI system such as colon and small intestine; code to the GI tract, NOS (C269). Document the possible primary sites in a text field.
  • Diagnosis of malignancy in transplanted section of colon serving as esophagus. Code the primary site as esophagus. Document the situation in a text field.
  • If the patient’s age is 100 years or older, check the accuracy of the date of birth and date of diagnosis, and document both in a text field.
  • Use the associated text field to document why a particular race code was chosen when there are discrepancies in race information. Example: The patient is identified as Black in nursing notes and White in a dictated physical exam. Use a text field to document why one race was coded rather than the other.

Random examples as provided in the current FORDS Manual:

  • Document the information to support coded tumor size in the appropriate text data item of the abstract.
  • If “Other Treatment” is coded then a complete description of the treatment plan should be recorded in the text field for “Other Treatment” on the abstract.

Jennifer Rohleder BS, CTR
Compliance Director, Oncology Data Management and Accreditation Services

 

References:

NPCR Education and Training Series (NETS) Module 4: The Value of Accurate Text in Cancer Registry Prepared by Scientific Applications International Corporation (SAIC) CDC Contract Number 200–2002–00576–0004 https://www.pdffiller.com/6006206-nets4pdf-NPCR-Education-and…

FORDS, 2016 American College of Surgeons (January 2016). American College of Surgeons 633 N Saint Clair Street Chicago, IL 60611-3211

Adamo M, Dickie, L, Ruhl J. (January 2016). SEER Program Coding and Staging Manual 2016, National Cancer Institute, Bethesda, MD 20850-9765. US Department of Health and Human Services National Institutes of Health National Cancer Institute.

 

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