A: This Has Been Sent to SEER for Clarification

Q&A Session Coding Pitfalls Thursday, September 06, 2012 ______Q: Slide 10 indicates that the diagnostic confirmation for nodular sclerosing Hodgkin lymphoma should be histology regardless of IHC testing. We've submitted a similar query (different disease) in which the response from SEER was that the database may not have included IHC/genetic testing under diagnostic methods. So my question is how do we know if it's a database oversight versus not applicable for the disease as indicated with nodular sclerosing Hodgkin lymphoma?

A: This has been sent to SEER for Clarification. ______Q: I asked a question during the last webinar regarding polycythemia vera diagnosed due to another condition. Do we add these cases to the database?

A: SEER is still looking into this issue! ______Q: In the solid tumor MP/H rules, "variant" is not a term we can use for histology. However, for the hematopoietic, can we use "variant" such as Hodgkin lymphoma, nodular sclerosing variant?

A: I entered Hodgkin lymphoma, nodular sclerosing variant into the database and received no results. I believe you would have to code that as Hodgkin lymphoma NOS. However, this has been sent to SEER for Clarification. ______Q: Just an FYI about CLL/SLL when only lymph node involvement. There is currently a problem with edits when you code the histology to 9823/3 and the primary site to C77._. I've been informed that the Edits committee is reviewing.

A: Thanks for letting us know. This is being reviewed by the NAACCR Edits Committee ______Q: On pop quiz on slide 30, what code would be used if the axillary nodes removed by sentinel lymph node biopsy were positive?

A: If axillary nodes are positive on sentinel node biopsy and axillary node dissection was NOT done, then the code for scope of regional lymph node surgery would still be 2. If axillary node dissection was also performed, assign the appropriate combination code, 6 or 7, depending on if the procedures were performed at the same time or different times. ______Q: In the description of the scope of regional lymph node surgery data item, it is stated that surgery must be performed. Just an FNA by itself is not surgery. Am I not reading the description right (page 205 of FORDS)? A: I am afraid I can't find anything stating surgery must be performed. The instructions say that each procedure to lymph nodes is coded even if surgery to primary site is not performed. The instructions also say that procedures to regional nodes to diagnose or stage (not just treat) are coded in scope of regional lymph node surgery. ______Q: Won't coding a failed sentinel lymph node biopsy (no LNs removed) cause an edit due to Regional Lymph Nodes Examined =0?

A: This will not trigger any edits in the NAACCR 12c metafile. If it does trigger an edit, you should contact your software vendor or state registry and ask them to correct the edit. ______Q: On slide 39, it states "and the number of grades in the system is known, code these two values in Grade Path System and Grade Path Value." Does the term KNOWN indicate "stated in the record" or can it be interpreted?

A: It needs to be stated. ______Q: For date of diagnosis in the question on slide 48, would the diagnosis be the date the physician stated the positive diagnosis or would it be the January date?

A: The diagnosis date should be the date the cancer was proven using terminology that constitutes a diagnosis of cancer. In this case, the diagnosis date would be February unless the physician documents that in retrospect the patient had cancer at the earlier date. ______Q: Looking at slide 51, for hematopoietic cases, if (cytology) FNA report includes "lymphoid tissue" with ambiguous term, will this be reportable?

A: See page 14 rule 4 in the 2012 Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual. Ambiguous terminology should not be used with cytology when determining reportability. This is consistent with the rules for solid tumors. ______Q: If CT of kidney says consistent with renal cell carcinoma, is that sufficient for a date of diagnosis?

A: "Consistent with" is ambiguous terminology that constitutes a diagnosis of cancer. The CT could be used to code the date of diagnosis. ______Q: Please clarify on slide 48 that if the term "suspicious for" would be reportable.

A: Suspicious for is reportable ambiguous terminology. Therefore, January would be the diagnosis date. ______Q: If you have a suspicious neoplasm of breast on mammogram is this reportable? A: No. "Neoplasm" has a behavior code of /1 (borderline malignancy). Borderline malignancy cases are only reportable if the primary site is in the central nervous system. Ambiguous terminology must be used with a reportable term to be reportable. ______Q: What is the grade code for high grade soft tissue sarcoma?

A: You need to know the primary site. For certain sites with sarcoma, grade is coded in CS SSF1. Those sites can be found on page 11 of FORDS. For example, if primary was high grade sarcoma of peripheral nerve of face (C47.0), high grade would be coded in SSF1, not in the grade data item IF you are following FORDS coding instructions. ______Q: Isn't colon on the special grades table in FORDS?

A: Yes. The table indicates that “tumor regression grade” should be collected in the Colon schema site- specific factor. It should not be used to convert to grade/differentiation. ______Q: In reference to question 10 on quiz 1, please explain why the code for Grade/Differentiation is 9?

A: FORDS says that if you have enough info to code grade path value/grade path system, you can code grade/differentiation 9. ______

Q: I have a question that's not going to be addressed per handouts. FORDS 2010/page 108 states: “code laterality for all paired sites”. I see the paired sites list on page 9. BUT in the last bullet on page 108 FORDS states: “non-paired sites MAY be coded right/left IF APPROPRIATE”. Could this possibly apply to a non-paired organ which crosses midline of body (thyroid/transverse colon) and has cancer confined to either right or left side of midline?

A: It is my understanding that the instructions, ‘non-paired sites may be coded right/left if appropriate’ was included to allow registries to code laterality for sites like thyroid or prostate if they so choose. ______Q: In order to verify for our surgeons that the patient had a biopsy prior to mastectomy is it okay to enter 02 for biopsy to breast in the Surgical Diagnostic and Staging Procedure data item if the biopsy is negative (example: borderline carcinoma in situ)? Our surgeons want to verify that a biopsy was performed prior surgery.

A: Negative biopsy should not be coded in Surgical Diagnostic and Staging Procedures per the coding instructions in FORDS 2012 page 123. “Only record positive procedures. For benign and borderline reportable tumors, report the biopsies positive for those conditions. For malignant tumors, report procedures if they were positive for malignancy.” ______Q: If thyroid cancer is diagnosed on FNA/biopsy and then hormone is commenced prior to a subsequent thyroidectomy, would this then be CS TS/Ext Eval 5/6 even though' your slide indicates they are not aware of hormone as neoadjuvant therapy?

A: I suggest asking the physician or checking treatment guidelines such as the NCCN guidelines to determine if synthyroid is being used as neoadjuvant treatment for the thyroid cancer. If it is and it appears that it is being used as such for the case in question, then I would code eval as 5 or 6. If synthyroid is not used as neoadjuvant treatment, then do not code eval as 5 or 6. ______Q: If a physician makes a clinical diagnosis of cancer after a suspicious cytology but before a positive tissue biopsy, what is the date of diagnosis?

A: In that case the date of diagnosis would be the date the physician made the clinical diagnosis of cancer. ______Q: If you have a case with an unknown primary and later after death clearance the cause of death is lung cancer, can you change the primary site to Lung?

A: Follow your death clearance procedures to determine if it is one or two primaries. If you determine it is a single primary, I would change primary site to lung. ______Q: For melanoma LDH, if there are 2 positive tests, do both have to be within the timing of prior to treatment/within 6 weeks of diagnosis OR just the first test since that is the one that takes priority?

A: In my opinion, it should be prior to treatment or within 6 weeks of diagnosis for all tests. ______Q: Regarding colon & rectum SSF8 and the clarification for coding perinerual invasion as 999 if only biopsy is done; where is this clarification documented?

A: It is documented in the CAnswer Forum: http://cancerbulletin.facs.org/forums/showthread.php? 2237-SSF-8-and-Biopsy-only ______Q: If we have biopsy stating likely carcinoma, is this reportable?

A: It is my understanding that likely alone is not ambiguous terminology that constitutes a diagnosis of cancer. It must say 'most likely'. ______Q: Why on quiz 2 question 1 would you change the surgical procedure other?

A: The biopsy of the lymph node for the unknown primary would be coded under surgical procedure other code 1. For the lung primary it would be code 3. ______Q: In reference to question 9 from quiz 2, how do you know the cervical node is regional?

A: You don't know for sure, but the coding instructions tell you to code it that way when the primary melanoma is unknown. ______