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WCRS Coding Manual WCRS Coding Manual Wisconsin Cancer Reporting System (WCRS) Office of Health Informatics Division of Public Health Department of Health Services Updated for 2016 - 2017 Diagnoses Seventh Edition P-00832 (03/2017) Wisconsin Cancer Reporting System Division of Public Health Wisconsin Department of Health Services WCRS Coding Manual, 7th Edition February 2017 This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Wisconsin Department of Health Services #U58/DP12-1205 Wisconsin Cancer Reporting System on the Web: https://www.dhs.wisconsin.gov/wcrs/index.htm Wisconsin Cancer Reporting System Cancer Reporter’s Web Page: https://www.dhs.wisconsin.gov/wcrs/reporterinfo/index.htm WCRS Coding Manual Table of Contents Table of Contents ABOUT THIS MANUAL ................................................................................................... Preface OVERVIEW ................................................................................................................................... 1 What is the Wisconsin Cancer Reporting System (WCRS)? ............................................. 1 Why Report to WCRS? ....................................................................................................... 1 Who Reports to WCRS? .................................................................................................... 2 Data Exchange Agreements ................................................................................................ 3 What Information is Collected about Patients Diagnosed With Cancer? .......................... 3 How are Cancer Reports Submitted to WCRS and Processed? ......................................... 4 What is the Death Certificate Only Process? ..................................................................... 6 File Retention ..................................................................................................................... 7 Are There Measures of Quality Applied to the Cancer Registry? ..................................... 7 Is it Necessary to Submit Corrections or Changes to Records? ......................................... 8 What Is the Difference Between WCRS and Hospital Discharge Files? ........................... 8 What Does WCRS Do to Protect Privacy? ........................................................................ 9 What Kind of Data Does WCRS Release? ...................................................................... 10 Chapter 1: DETERMINING REPORTABILITY .................................................................... C1-1 Casefinding Techniques ............................................................................................... C1-1 Cases That Must Be Reported....................................................................................... C1-1 Disease Index Codes for Casefinding .......................................................................... C1-7 Nonreportable Cases .................................................................................................. C1-11 Ambiguous Diagnostic Terms .................................................................................... C1-12 Chapter 2: DETERMINING THE NUMBER OF PRIMARY TUMORS ............................... C2-1 Definitions..................................................................................................................... C2-2 Determining Multiple Primaries for Solid Malignant Tumors – General Instructions . C2-3 How to Use the Multiple Primary Rules ....................................................................... C2-3 Determining Histology for Solid Malignant Tumors – General Instructions ............... C2-5 How to Use the Histology Coding Rules ...................................................................... C2-5 Priority Order for Using Documents to Code Histology .............................................. C2-6 Ambiguous Terms Used to Code Histology ................................................................. C2-7 Example of Flow Chart, Matrix and Text Formats ....................................................... C2-8 Chapter 3: GENERAL INSTRUCTIONS ................................................................................ C3-1 Important Items to Remember ..................................................................................... C3-1 General Coding Instructions for Place of Residence at Diagnosis ............................... C3-4 General Coding Instructions for Reporting Race .......................................................... C3-6 General Coding Instructions for Reporting Ethnicity ................................................. C3-10 General Coding Instructions for Reporting Behavior ................................................. C3-11 General Coding Instructions for Reporting Grade ...................................................... C3-13 Changing Information Already Reported to WCRS ................................................... C3-24 Paper Abstracts ........................................................................................................... C3-24 iii WCRS Coding Manual Table of Contents Electronic Data Transmissions ................................................................................... C3-25 Chapter 4: FIRST COURSE OF THERAPY ........................................................................... C4-1 Chapter 5: DATA DICTIONARY ........................................................................................... C5-1 APPENDICES ............................................................................................................................ A-1 I. WCRS Contact Information ............................................................................................ A-1 II. Laws Governing Wisconsin Cancer Reporting............................................................... A-2 III. Comparison of Hospital and Nonhospital Cancer Reporting Procedures ....................... A-9 IV. WCRS Reference Materials Websites .......................................................................... A-11 V. Race and Nationality Descriptions................................................................................ A-13 VI. Site-Specific Factors Required for 2016 and 2017 ....................................................... A-22 VII. Pediatric and Young Adult Early Case Capture Required Data Items ......................... A-27 VIII. Continued Use of ICD-O-3 Histology Code Crosswalk ............................................... A-30 iv WCRS Abstract Code Manual Preface ABOUT THIS MANUAL The primary purpose of this WCRS Coding Manual is to assist Wisconsin cancer reporters in reporting cancer cases to the Wisconsin Cancer Reporting System (WCRS). If questions arise that can’t be answered from the materials provided in this coding manual or other resources cited within, call or email the WCRS staff for further assistance. Please see Appendix I for WCRS staff contact information. Since the passage of Public Law 102-515, the Cancer Registries Amendment Act, by the 102nd Congress in October 1992, there has been a tremendous effort by all national agencies collecting cancer data to unify and standardize data sets. With the establishment of the National Program of Cancer Registries (NPCR) in 1994, all central registries funded by the Centers for Disease Control and Prevention (CDC) through NPCR are required to follow stringent data management procedures; provide training for state personnel and hospital/clinic reporting staff; publish an annual report; and conduct casefinding and re-abstracting audits at randomly selected facilities. Although WCRS began receiving CDC/NPCR funding in 1995, the registry was established in 1976 by the Wisconsin Legislature; therefore our index (reference) year is 1976. WCRS collects data that: 1) are compliant with required NPCR data elements; 2) meet standard requirements designated by the North American Association of Central Cancer Registries (NAACCR) for incidence reporting and endorsed by CDC; and 3) assist WCRS staff when assessing data quality. WCRS also uses the data to provide useful feedback to submitting facilities for quality assurance activities and administrative purposes. The following Overview section of this manual addresses frequently asked questions about the “what, why, who, when and how” of cancer reporting. WCRS Coding Manual Overview OVERVIEW WHAT IS THE WISCONSIN CANCER REPORTING SYSTEM (WCRS)? The Wisconsin Cancer Reporting System (WCRS) collects and processes information on cancer cases in Wisconsin. In addition, WCRS provides data and produces reports on cancer incidence and mortality statewide and other geographic areas in Wisconsin, by gender and anatomic site (i.e., breast, lung, colon, prostate, etc.), and by stage of disease. Because of its comprehensive database of information on cancer cases in Wisconsin, WCRS serves as an important resource for citizens, health care professionals and researchers. One of the oldest cancer registries in the country, WCRS has been collecting information on Wisconsin residents with cancer for over 40 years. The first state mandate requiring hospitals and physicians to report cancer cases diagnosed in Wisconsin was passed in 1976 by the Wisconsin State Legislature. WCRS began collecting data from Southeast Wisconsin that year. In 1978, WCRS began collecting data statewide. In 1995, WCRS began receiving additional funding from the Centers for
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