STEP 2: Identification of recurrence (local, regional or distant metastases) based on electronic health record algorithm using automated databases:

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Cori Parker
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1 Appendix 1. Specifications for identifying subsequent breast cancer STEP 1: Identification of second primary breast cancer Identification based on key variables from Cancer Registry including date of diagnosis; stage of second primary; laterality; histology and sequence number. STEP 2: Identification of recurrence (local, regional or distant metastases) based on electronic health record algorithm using automated databases: Disease recurrence identified by breast cancer ICD9 diagnosis of 174.xx or or 155.xx or 162.xx or 163.xx or 170.xx or 191.xx or193.xx or 194.xx or 195.xx or 196.xx or 197.xx or 198.xx or 199.xx or 212.xx or 213.xx or 255.xx or or or or or or or 733.1x or (CDAP, KP code of 1083, 3690, 3691) or ICD10 C50 (at least six months after the index cancer AND after 1st primary surgery) OR (six months after 1st chemotherapy) PLUS any of the below procedure codes occurring +/- 30 days from the date of the ICD9 disease code: BIOPSY/IMAGING/SURGERY : Biopsy, superficial fine needle aspiration without imaging guidance Fine needle aspiration; with imaging guidance Biopsy of breast, percutaneous core, without imaging guidance Biopsy of breast; open incisional Biopsy breast percutaneous core needle w ultrasonic guidance Biopsy breast; perc-vacuum dev w/imaging Imaging guided plc clip-perc-dur breast Mastectomy, partial Mastectomy, partial; with axillary lymphadenectomy Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes Mastectomy, modified radical, including axillary lymph nodes, w/ w/out pectoralis minor muscle, but excluding pectoralis major muscle Immediate insertion of breast prosthesis following mastectomy Delayed insertion of breast prosthesis following mastectomy Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with TRAM, single pedicle, including closure of donor site Breast reconstruction with TRAM, single pedicle, including closure of donor site; with Microvascular anastomosis Breast reconstruction with TRAM, double pedicle, including closure of donor site Biopsy superficial bones with trocar or needle Biopsy deep bones with trocar or needle Biopsy of bone other

2 32095 Open biopsy of lung or pleura (Limited without exploration) Open biopsy of lung or pleura with exploration (Major) Percutaneous biopsy of lung or mediastunum (Transthoracic) Selective catheter of liver Transcatheter biopsy of liver Biopsy of bone marrow Percutaneous needle biopsy of liver Open biopsy of Liver also called wedge biopsy Stereotactic radiosurgery (particle beam, gamma-ray, linear accelerator),one or more sessions Transcatheter biopsy S/I of Liver XR surgical specimen Magnetic image, bone marrow ECHO guide for biopsy ECHO exam of breast(s) Fluoroscopic guidance for needle placement, injection or asp CT guidance for stereotactic localization CT guidance for needle biopsy MRI Guidance for needle placement; Rad supervision & interpretation XR mammogram, stereotactic loc Mammographic guidance needle placement ea lesion of breast, Computer-aided detection, w/or w/o radiographic images; diagnostic mammography Computer-aided detection, w/or w/o radiographic images; screening mammography XR mammary ductogram single duct, right ductogram, multiple duct XR mammography, diagnostic Mammography diagnostic, bilateral XR mammogram, screening MRI Breast w/and/or w/o contrast unilateral MRI Breast w/and/or w/o contrast bilateral Stereotactic radiation treatment management of cerebral lesion(s) Bone marrow imaging, limited Bone marrow imaging, multiple Bone marrow imaging, whole body Liver imaging Liver imaging w flow Liver imaging spect Liver imaging spect w vascular flow Bone or joint imaging ltd Bone or joint imaging multiple Bone scan whole body Bone scan 3 phase study Bone joint imaging tomography test spect Brain imaging ltd static Brain ltd imaging and flow Brain imaging complete Brain imaging complete w flow Brain imaging spect Brain flow imaging only Brain imaging, positron emission tomography (pet) metabolic evaluation Brain imaging, positron emission tomography (pet), perfusion evaluation

3 : Breast biopsy Closed breast biopsy Open breast biopsy Local excision breast lesion Quadrant resect breast Subtotal mastectomy Lymph node removal Excise axillary node Simple excise lymph strucnec 40.3 Regional lymph node exc Mastectomy Unilateral simple mastectomy Bilateral simple mastectomy Unilateral Extend simple mastectomy Bilateral Extend simple mastectomy Unilateral radical mastectomy Bilateral radical mastectomy Liver Biopsy Closed (percutaneous, needle, biopsy of liver) Liver biopsy, open Lung Biopsy Closed [Percutaneous] [Needle] Biopsy of Lung Closed Endoscopic Biopsy of Lung Lung Biopsy, Open Bone Biopsy Bone biopsy nos Chest cage bone biopsy Humerus biopsy Radius & ulna biopsy Metacarpal/carpal biopsy Femoral biopsy Patellar biopsy Tibia & fibula biopsy Metatarsal/tarsal biopsy Bone biopsy nec Bone Marrow Biopsy Bone marrow biopsy Brain Biopsy Closed brain biopsy Open brain biopsy Imaging

4 88.91 MRI brain & brain stem Liver scan and radioisotope function study Bone scan CYTOLOGY Thoracentesis, puncture of the pleural cavity for aspiration, initial or subsequent Thoracentesis with insertion of tube, includes water seal, when performed (separate procedure) Biopsy, pleura; percutaneous needle Thoracentesis, puncture of the pleural cavity for aspiration, initial or subsequent Thoracentesis with insertion of tube, includes water seal, when performed (separate procedure) Cytology Respiratory Tract (Sputum, Bronchial, Wang Needle, Pneumocystis) Body Cavity (Pleural, Peritoneal, and Pericardial fluid) Cytology Respiratory Tract (Sputum, Bronchial, Wang Needle, Pneumocystis) Fine Needle Aspiration Pleural Fluid Thoracentesis (pleural fluid analysis) CHEMOTHERAPY (At Least 6 Months after 1st Chemotherapy): Chemotherapy Chemotherapy Oral Chemo Agents Abraxane (Paclitaxel) Bevacizumab (Avastin) Busulfan Capecitabine (Xeloda) Carboplatin Cyclophosphamide Docetaxel Docetaxol (Taxotere) Doxorubicin Epirubicin Etoposide Fluorouracil Fulvestrant Gemcitabine Liposome Doxorubicin Melphalan Methotrexate (Oral Injection Only, Not Tablets) Paclitaxel (Taxol) Rhumab-Vegf Rituximab

5 Temozolomide Vinorelbine RADIATION THERAPY (If didn't receive radiation therapy as 1st course of treatment) Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy Radiation therapy G0256 Radiation therapy G0261 Radiation therapy OTHER INDICATORS OF RECURRENCE Disease recurrence identified by breast cancer ICD9 diagnosis of 174.xx or or 155.xx or 162.xx or 163.xx or 170.xx or 191.xx or193.xx or 194.xx or 195.xx or 196.xx or 197.xx or 198.xx or 199.xx or 212.xx or 213.xx or 255.xx or or or or or or or 733.1x or (CDAP, KP code of 1083, 3690, 3691) or ICD10 C50 at least 12 months after the index cancer AND after 1st primary surgery PLUS any of the below utilization categories occurring +/- 60 days from the date of the ICD9 disease code: Oncology Visits(Clustering of quarterly oncology visits/hospitalizations) If patient has more than 1 visit within a three month period more than a year after initial diagnosis. Drug Switching from Tamoxifen to AI If long break (12+ Months) in TAM therapy and then therapy resumes (AI). Hospice/Palliative Care Utilization If encounter for hospice/palliative care (ICD code V66.7) or physician supervision of a hospice patient (CPT 99377). Pain Medication Utilization (Prescribed by Oncologist) Opioids/Narcotics STEP 3: Distinguish identification of recurrences from second breast primary cancers Identify first surgery date after initial breast cancer Dx (from cancer registry, pathology, electronic databases). Compare date of procedure used to identify recurrence to that of first surgery date. If procedure occurs before 1 st surgery, should NOT be considered a recurrence. If the date of second primary breast cancer (from cancer registry) is within 30 days of the recurrence, ignore recurrence and code as a second primary.

FY16 BCCS Reimbursement Rates and Billing Guidelines Appendix B 2

FY16 BCCS Reimbursement Rates and Billing Guidelines Appendix B 2 77053 Mammary ductogram or galactogram, single duct, Global Fee $59.05 May be billed with 77055, G0206, 77056, G0204, 76641, 76642 Billable