Part VIII Entering Information Into the Urology Report Form

Transcription

1 North Carolina Central Cancer Registry Instructions and Reporting Requirements Module 8 Electronic Reporting For Urology Physician Practices May 2013 North Carolina Central Cancer Registry State Center for Health Statistics Division of Public Health Department of Health and Human Services 1908 Mail Service Center Raleigh, NC

2 Part VIII Entering Information Into

3 Before beginning a new report, read the following VERY IMPORTANT information A separate report must be completed and submitted for each independent primary tumor. o Example: If a patient is diagnosed with bladder cancer and a separate kidney cancer, a separate report must be submitted for each diagnosis. o Please complete the urology reporting form as ACCURATELY and COMPLETELY as possible. o Once the report is free of errors and is successfully submitted, it is considered as having been reported to the NCCCR.

4 Before opening a new reporting form and beginning data entry: o Make sure all information necessary for entering the case is available and on hand o Review the chart in its entirety o Make notes on a note pad or scrap paper if necessary to facilitate data entry o Confirm any information that is confusing or unclear with the physician. Session times out after 30 minutes if no activity takes place. o All information entered for the case (and not submitted) will be lost. o All information necessary for completing the case should be on hand prior to beginning data entry for that case.

5 There is no Save functionality o Users must be able to complete data entry for the current case during the active session. o Cases are not saved until the case is completely entered, one of the Submit options is selected, and all error messages are cleared. o 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. o Cases started, but not completed, cannot be accessed at a later time. o Any information will be lost and must be re-entered when the complete information is available.

6 Treatment information is very important: o Wait to enter report AFTER treatment plan is established Make sure START DATES for each treatment modality are known o It is not required for all treatment to be completed Treatment may continue for months or years o For 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.

7 Text is CRITICAL! o Over 100 additional data items will be coded by the NCCCR staff after the report is submitted. o This coding is highly dependent on the text you provide. o Provide as much information and detail as possible to describe the case. o It is critical to the accuracy and completeness of the final coding for the reported case.

8 Screen Shots o A 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 case o A table per screen shot is included with information on Each data field on the tab Any additional coding instructions for each tab o Pay particular attention to the format and content of the text areas used to describe the case A red asterisk [*] indicates a required field Text boxes allow a limited number of characters o Hover over the box with the mouse pointer to display information about the maximum number of characters allowed

9 Section VIII.1: Entering Patient Personal Data on the Demographic Tab

10 Section VIII.1: Entering Patient Personal Data on the Demographic Tab - continued Last Name* First Name* Middle Suffix Medical Rec # SSN* Special characters (,. / : # & *) are not allowed in name fields. Enter the name without special characters. For example, enter OHARA for O Hara. Letters, numbers and periods only are allowed. Letters, numbers and hyphens only are allowed. The SSN can be entered with or without hyphens. Unknown should be avoided is only allowed if the patient refused to provide their SSN. Sex/Gender* Insurance Birth Date* Place of Birth Race* Spanish Origin Vital Status Unknown should be avoided. Date of birth may not be blank or unknown. Code 999 (unknown) if not specifically stated. Do not assume patient was born in the U.S. 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. If 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 1 5. 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. The Vital Status should remain Alive unless there is documentation of the patient s death prior to reporting the case.

11 Section VIII.1: Entering Patient Personal Data on the Demographic Tab - continued Date of Death If Date of Death is entered, it must be the latest date entered in the record. Date of Death Flag If Vital Status is Alive, leave the default flag of 11. If Vital Status is Dead, set the flag to12 ONLY if exact date is not known. If the date of death is known, this flag should be left blank. 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. Industry and Occupation Date first seen with Cancer Date of Last Appt. Record the occupation and industry where the patient worked for the majority of their lifetime. Example: Industry: Education, Occupation: Teacher If the usual occupation is not clear, enter the current occupation. If no information is known about the patient s 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. This is the first date the patient was seen at your office with a diagnosis of cancer. If the patient is diagnosed as a result of testing performed during the office visit, the date will be the date of this visit. This should not be blank or unknown. This is the last date the patient was seen at your office, regardless of the reason for the visit or the disease status. This should not be blank or unknown.

12 Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab Cannot be unknown. Estimate as closely as possible. Check this box ONLY WHEN the next case to be entered will be for the SAME patient. Each procedure must include: Date, Procedure, Place, Findings. Don t forget Age, Sex and Race. Use any available text field to provide additional pertinent information. Pathology information is very important. Be very detailed.

13 Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued Keep Patient Address check box Check this box ONLY WHEN the next case to be entered will be for a DIFFERENT primary cancer for the SAME patient. For example, the patient has a bladder primary cancer and a separate kidney primary cancer to be reported. Important: This can be a real time saver but MUST be cleared when the next case will be for a different patient. Date of Dx* Place of Dx Enter the first date it was stated the patient had this cancer. This may be a physician s 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 patient s first visit to your office. 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. Enter the facility, treatment center, or physician s office that performed the first test or made the first statement that confirmed this diagnosis. If this was at your office, then enter your office name. If this is unknown, then record UNKNOWN.

14 Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued 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 patient s 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 City* Should be the street address. PO Box is allowed but should only be used if the physical address is not known. State* Zip* County* If the last four digits of the zip code are known, enter them preceded by a hyphen. 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 County is unknown. This is only allowed if the city is unknown.

15 Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued 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 Exam Include age, rage and sex of patient Include 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 Include the results of any imaging tests performed to evaluate the tumor Scopes This includes endoscopies, ultra-sounds, etc. Lab Values In 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. Routine blood tests such as CBC do not need to be included

16 Section VIII.2: Entering Diagnostic Data on the Dx/Staging Tab - continued 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 report Location 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 Gleason Tumor Size Tumor extension into other surrounding tissues Surgical Margins # Lymph Nodes removed and positive Examination of metastatic tissues Ancillary studies such as tumor markers Relevant findings from the gross examination including aids in identifying the primary site and extent of disease

17 Section VIII.3: Entering Facility Data on the Hospital Tab

18 Section VIII.3: Entering Facility Data on the Hospital Tab - continued Facility 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. Both Submit buttons will retain the facility information for subsequent cases entered during this active session. Facility Name* Address 1* and Address 2 City* State* Zip* County* Facility #* Enter the official name of the facility you are reporting cases for. Post Office Box addresses are not accepted for Facility address. Use the drop down menu to make a selection. Type the county name to begin the search. Unknown is not allowed. Select the Facility Identification Number assigned to the physician office in which you are reporting cases. This was the number assigned to your office when you requested a Eureka account.

19 Section VIII.3: Entering Facility Data on the Hospital Tab - continued If the patient was seen at another hospital, treatment center or physician s 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 physician s office for the Referred From of Referred To fields was not an available option in the associated selection boxes, leave the default o 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 From Referred To Attending MD Surgeon NPI Numbers Patient seen elsewhere for management of this tumor before visit at your office. If the patient was not referred, leave the default of Patient seen elsewhere for the management of this tumor after visit at your office. If the patient was not referred, leave the default of Enter the name of the physician at your office caring for the patient. Enter the name of the physician who performed the cancer-directed surgery for the treatment of this tumor. For 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 office 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): Click on Data Dissemination

20 Section VIII.4: Entering Tumor Data on the Tumor Data Tab Must be recorded in MM. Convert CM to MM. If the patient did not receive that particular type of treatment, select the flag code of 11. 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. Text describing the primary site and histology (including behavior and grade) MUST be included here to validate the codes selected above.

21 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued Site* Select the organ/tissue in which the primary tumor arose/originated. Only the codes for urinary related sites have been provided in the drop down menu. If the exact site cannot be identified, but it is known to have originated in the urinary tract, select code C68.9 Urinary System, NOS If the exact site cannot be identified, but it is known to have originated in the male genital / genitourinary tract, select code C63.9 Male Genital, NOS Codes 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 Confirmation Select 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.

22 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued Histology* Select the code that best describes the histology of the tumor. Only histologies that commonly arise in urinary related sites have been provided in the drop down menu. Record the histology based on the FINAL DIAGNOSIS (this includes addendums, comments and revised/amended diagnoses) of the pathology report that contained the most representative tumor specimen examined. If there was not a pathology report, use the following priority order to identify which report best represents the histology to be coded. Cytology report Documentation in the record that references pathology or cytology findings Any mention of the type of cancer (histology) in the medical record. If the exact histology is not listed in the menu, select the term that best matches the histology. If that cannot be done, code to 80003, Malignancy NOS Note: It is very important to enter the description of the site and histology EXACTLY as stated in the pathology report (or record). Pay particular attention to the behavior code in the drop down list. The behavior code is the number at the end of each code. Many terms are listed twice, once as in situ (ends with 2) and another as invasive (ends with 3). Select the code with the appropriate behavior code to describe whether the tumor was in situ (/2) or invasive (/3)

23 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued Laterality* Tumor Status Tumor Size If the primary site is a bilateral organ, the side in which the tumor originated (laterality) must be specific. The following are the paired organs for urinary related sites only. C62.0 C62.9 Testis C63.0 Epididymis C63.1 Spermatic cord C64.9 Kidney, NOS C65.9 Renal pelvis C66.9 Ureter Use code 0 for all other non-paired organs Use code 4 if the following conditions are met (e.g. bilateral Wilm s tumors): There was a bilateral involvement at time of diagnosis, It contained the same histology, And it is considered a single primary. At the time of the last visit to your office, indicate whether the patient had evidence of this disease or was considered disease free. Record the largest dimension or diameter of the primary tumor. Must be exactly three numbers. Enter leading 0 s to equal three numbers. Record the tumor size in millimeters. Convert centimeters to millimeters by multiplying the dimension by 10. Tumor is 2.5 cm. Record as 025 (2.5 cm = 25 mm) Tumor is 4 cm. Record as 040 (4 cm = 40 mm) Round up or down to the nearest millimeter Tumor is 6.5 millimeters. Record as 007 (round up) Tumor is 2.3 millimeters. Record as 002 (round down) Record 999 if the tumor size is unknown or not stated.

24 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued 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 three 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* Mets at Dx* Lymph Node involvement* From all of the workup performed, summarize the extent of the primary tumor. Summarize the following: Tumor size Involvement with the primary organ Extension into surrounding tissues. 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. 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 involved Number of lymph nodes involved Number of lymph nodes examined Any documentation that the lymph nodes were evaluated and were negative.

25 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued 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 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, Text Record 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 dates Place/facility given Area of body treated Modality (type, energy) Dose (amount of radiation)

26 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued Surgery Date, Flag, Text Record 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 date Place/facility performed Chemo Date, Flag, Text Hormone Date, Flag, Text Immunotherapy Date, Flag, Text Other Treatment Date, Flag, Text 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. For 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 dates Place/facility given Name of each drug/treatment given Note: 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.

27 Section VIII.4: Entering Tumor Data on the Tumor Data Tab - continued Remarks Required text: This is very important in making sure the best site and histology codes are recorded during final coding by the NCCCR staff. Record the following EXACTLY as stated in the medical record: Primary site, including exact subsite and laterality. Histology, including whether it was invasive or in situ, and the grade (including site specific grading systems). Include descriptive phrases such as consistent with, probably, suggests, with features of, abutting, extending to, 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 their lifetime, regardless if it is being reported by your office. 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.

28 Section VIII.4: Entering Tumor Data on the Tumor Data Tab continued 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(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.

29 Part VIII Entering Information Into Completed