WELSH INFORMATION GOVERNANCE & STANDARDS BOARD

Transcription

1 WELSH INFORMATION GOVERNANCE & STANDARDS BOARD CCC Notice: CCCN 2011/01 Date of Issue: 18 April 2011 Ministerial / Official Letter: n/a Subject: Morphology Coding Sponsor: Head of Information Standards Implementation Date: 1 st May 2011 CLINICAL CODING CHANGE NOTICE A Clinical Coding Change Notice (CCCN) is the method of notification used when there is a new Clinical Coding Welsh Standard. This CCCN was approved by the Clinical Coding Advisory Group and the Welsh Information Governance and Standards Board (WIGSB) at its meeting on the 14 th April WIGSB Reference: Summary: This notice formalises morphology coding guidance issued by the All Wales Clinical Coding Tutor in January 2005 and describes clinical coding standards issued by the Welsh Cancer Intelligence & Surveillance Unit (WCISU) to assist clinical coders in the recording of accurate neoplasm and morphology clinical codes. The classification affected: ICD-10 Please address enquiries about this Clinical Coding Change Notice to the All Wales Clinical Coding Team in NHS Wales Informatics Service (NWIS) clinical.coding@wales.nhs.uk Tel: The Welsh Information Governance and Standards Board is responsible for appraising information standards. Submission documents and WIGSB Outcomes relating to the approval of this standard can be found at: CCCN 2011/01 Page 1 of 10

2 CLINICAL CODING CHANGE NOTICE MORPHOLOGY CODING Introduction Clinical coders routinely record ICD10 neoplasm codes on their hospital PAS systems. A Welsh standard states that the morphological type of the neoplasm should also be recorded and submitted to the Patient Episode Database for Wales (PEDW). This database is currently the primary data source for the Welsh Cancer Intelligence and Surveillance Unit (WCISU). WCISU acts in an advisory capacity on neoplasm aspects of the ICD classification and morphology coding queries. The 2005 letter issued by the All Wales Clinical Coding Tutor contained guidance which aimed to assist clinical coders with the assignment of morphology codes not easily indexed in the ICD-10 clinical coding classification. As set out in the description of change, the aim of this notification is to: 1) Formalise the guidance issued by the All Wales Clinical Coding Tutor in 2005; 2) Identify recent changes to that guidance and; 3) Introduce new guidance for clinical coders for the assignment of morphology codes which are not easily indexed in the ICD-10 clinical coding classification. The guidance contained in this document has been ratified by the Executive Committee of the United Kingdom Association of Cancer Registries (UK ACR). The advice should be used in conjunction with other NHS Classifications Service and Welsh Coding Standards. CCCN 2011/01 Page 2 of 10

3 Description of Change 1. FORMALISE GUIDANCE ISSUED IN 2005 For newly diagnosed patients (i.e. the first time a diagnosis is coded on inpatient episode) the following clinical coding guidance applies. 1.1 Mature Teratomas The morphological type described in a diagnostic statement of: a) Testicular mature cystic teratoma should be coded to M9080/1 Teratoma, NOS b) Mature cystic teratoma of the ovary should be coded to M9080/0 Teratoma, benign 1.2 Paget s Disease Breast The morphological type described in a diagnostic statement of: Paget s Disease, Breast should be coded to M8540/3 Paget s disease, mammary Please note ICD10 indicates that the topography code to be allocated with this morphological type is C50.0 Malignant neoplasm of breast nipple and areola 1.3 Neurofibromatosis: The morphological type described in a diagnostic statement of: a) Neurofibromatosis should be coded to the following topography category Q85 Phakomatoses nec Specifically Q85.0 Neurofibromatosis (non-malignant) b) Malignant Neurofibromatosis should be coded to M9540/3 Neurofibrosarcoma 1.4 B Cell Lymphoma NOS The morphological type described in a diagnostic statement of B-Cell lymphoma, unspecified (indexed to topography code C85.1) should be coded to M9590/3 Malignant lymphoma, NOS CCCN 2011/01 Page 3 of 10

4 1.5 Tumours of Endometrium The morphological type described in a diagnostic statement of: a) Adenocarcinoma with squamous differentiation should be coded to M8560/3 Adenosquamous carcinoma b) Adenocanthoma should be coded to M8570/3 Adenocarcinoma with squamous metaplasia 1.6 Malignant peripheral nerve sheath tumours The morphological type described in a diagnostic statement of: Malignant peripheral nerve sheath tumour should be coded to M9540/3 Neurofibrosarcoma 1.7 Endometrial intraepithelial neoplasia Grade III The morphological type described in a diagnostic statement of EIN III of the endometrium should be coded to M8140/2 Adenocarcinoma in situ, NOS 1.8 Laryngeal intraepithelial neoplasia Grade III The morphological type described in a diagnostic statement of LINIII of the Larynx should be coded to M8070/2 Squamous cell carcinoma in situ, NOS 1.9 Gastrointestinal Stromal Tumour (GIST): The morphological type described in a diagnostic statement of : a) Malignant Gastrointestinal Stromal Tumour should be coded to M8990/3 Mesenchymoma, Malignant b) Gastrointestinal Tumour should be allocated morphology code to M8990/1 Mesenchymoma NOS 1.10 Mixed Tumours composed of CINIII and CGINIII components The morphological types both included in a diagnostic statement of: CINIII with CGINIII should be coded to M8560/2 Adenosquamous Carcinoma in situ CCCN 2011/01 Page 4 of 10

5 2. CHANGES TO 2005 GUIDANCE 2.1 Mixed Tumours composed of CINIII and CGINIII components For activity with an episode end date on or between 1 st January 2005 and 30 th April 2011, the presence of both the morphological types in a diagnostic statement of: CIN III and CGIN III should be coded to M8560/2 Adenosquamous Carcinoma in situ For activity from 1 st May 2011 the presence of both the following morphological types in a diagnostic statement should be coded as follows: a) High grade CIN/CIN III should be coded to M8077/2 Intraepithelial neoplasia, grade III, of cervix, vulva and vagina b) High grade CGIN/CGINIII should be coded to M8140/2 Adenocarcinoma in situ, NOS Please note that 2 topography codes will also need to be recorded. 3. NEW CLINICAL CODING GUIDANCE FOR THE ASSIGNMENT OF CODES From 1 st May 2011, for newly diagnosed patients (i.e. the first time a diagnosis is coded on inpatient episode) the following clinical coding guidance applies. 3.1 Lymphomas The diagnostic statement of: a) Mucosa associated lymphoid tissue (Maltoma/Malt lymphoma) should be coded to: C857 Other specified types of non Hodgkin s lymphoma. M9711/3 Monocytoid B-cell lymphoma. b) Marginal zone lymphomas should be coded to: C857 Other specified types of non Hodgkin s lymphoma. M9711/3 Monocytoid B-cell lymphoma. 3.2 Giant Cell Tumours of Tendon Sheath Results of routine validation studies have show that some clinical coders have assigned the code M9251/1 Giant cell tumour of soft parts, NOS with the CCCN 2011/01 Page 5 of 10

6 appropriate site code to the above diagnostic statement. However, in the UK pathologists regard this diagnosis as a benign tumour. These tumours should therefore be coded to: M9040/0 Synovioma, benign 3.3 Mixed Transitional Cell (Urothelial) Carcinoma and Small Cell Carcinoma Bladder) The morphological types included in a diagnostic statement of: a) Transitional Cell /Urothelial carcinoma should be coded M8120/3 Transitional cell carcinoma NOS b) Small Cell Carcinoma should be coded M8041/3 Small cell carcinoma NOS c) Small Cell Large Cell Carcinoma should be coded to M8045/3 Small cell-large cell carcinoma 3.4 Renal Cell Clear Cell Carcinoma/Adenocarcinoma of Kidney It is possible for a diagnosis of Renal Cell Clear Cell Carcinoma to be reported by a pathologist. In the UK, it has been agreed to use the more descriptive morphology code of M8310/3 when Renal Cell Clear Cell Carcinoma is reported by a pathologist. Therefore the morphological type described in a diagnostic statement of: a) Renal Cell Carcinoma/Adenocarcinoma should be coded to M8312/3 Renal cell carcinoma b) Clear Cell Carcinoma/Adenocarcinoma should be coded to M8310/3 Clear cell adenocarcinoma NOS c) Clear Cell Renal Cell Carcinoma/Adenocarcinoma should be coded to M8310/3 Clear cell adenocarcinoma NOS 3.5 Early Stromal Invasion of Cervix When the diagnostic statement states that Early Stromal Invasion (ESI) of the cervix is present it should be dealt with as a microinvasive neoplasm and accordingly be coded to a malignant behaviour /3 i.e. the morphology code which should be allocated is M8076/3 Squamous cell carcinoma, microinvasive CCCN 2011/01 Page 6 of 10

7 3.6 Haemangiomas When the diagnostic statement is: a) Haemangioma of the Central Nervous System (CNS) the tumours should be recorded with the appropriate site D32 or D33 with morphology M9120/0. b) Epidermoid cyst of the CNS should be allocated the appropriate site code from D32/D33 with the morphology code M9084/0 Dermoid Cyst NOS 3.7 Differentiated Vulval Intraepithelial Neoplasia (VIN) When the diagnostic statement is Differentiated VIN (which is a very rare condition) it should be recorded as an in situ squamous lesion and allocated the morphology code M8070/2 Squamous Cell Carcinoma in situ 3.8 Primary Acquired Melanosis of Eye (PAM) A diagnostic statement of Primary Acquired Melanosis of the eye with severe atypia should be recorded as D03.8 Melanoma in situ of other sites M8741/2 Precancerous melanosis, NOS 3.9 In situ Skin Neoplasms Diagnostic statements with the following terminology should be allocated the morphology codes indicated with the appropriate site code (D04.-). Bowenoid Actinic Keratosis M8081/2 Bowenoid Keratosis M8081/2 Bowenoid dysplasia M8081/2 Full thickness dysplasia M8070/ Melanocytic Tumour of Uncertain Malignant Potential (MELTUMP) A diagnostic statement of Melanocytic Tumour of Uncertain Malignant Potential (MELTUMP) are to be classed as tumours of uncertain behaviour and should be assigned the morphology code M8720/1 Melanoma Uncertain Behaviour CCCN 2011/01 Page 7 of 10

8 3.11 PEComa PEComas are mesenchymal neoplasms with a distinct perivascular epithelioid cell differentiation (PEC). They are a family of tumours which includes angiomyolipoma, clear cell sugar tumour of the lung (CCST), lymphangiomyomatosis (LAM), clear cell myomelanocytic tumour (CCMMT) and others. Some of the members of the group are well recognised and have appropriate ICD10 codes (e.g. angiomyolipoma M8860/0, lymphangiomyomatosis M9174/1). However ICD10 does not contain an appropriate morphology code for PEComa NOS. Therefore the following morphology code should be assigned for a) PEComa - M8000/1 b) Malignant PEComa - M8000/ Mixed Epithelial tumours of the ovary The morphological type in a diagnostic statement of mixed epithelial tumours of the ovary should be coded as M8323/3 Mixed Cell Adenocarcinoma 3.13 Atypical tumours The behavior code to be allocated when the diagnostic statement indicates that a tumour is atypical is /1. e.g. Atypical carcinoma - M8010/1 Please note it may be necessary to add codes with t/1 to PAS look up tables. The fact that the appropriate code included in the ICD10 list of morphology codes does not mean that they should not be used. CCCN 2011/01 Page 8 of 10

9 Actions Required Local Health Boards and Trusts are asked to: 1. Ensure clinical coding staff apply the clinical coding guidance as outlined above with immediate effect. 2. Ensure that the morphology codes M9040/0 Synovioma, benign and M8720/1 Melanoma, uncertain behaviour are added to Patient Administration System (PAS) and associated clinical coding system look up tables The Welsh Cancer Intelligence & Surveillance Unit is asked to: 1. Ensure the morphology coding changes are reflected in any central analyses as outlined above. CCCN 2011/01 Page 9 of 10

10 Appendix A: CCCN Distribution List Linda Davies Lynda Rees Ann Wathan Tracey Francis Christine Thomas Helen Thomas Deborah Usher Chris Bird Sonia Stevens Cath Jones Paul Kelly Jean Edgeley Dafydd Ap Gwyn Jeff Pye Richard Walker Janet Holmes Christine Touma Richard Burdon Alan Roderick Steve Thomson Lisa Cartwright Gordon Craig Graham Crooks Karen O Doherty Shan Simkins Linda Edwards Anthony Tracey Sheila Davies Angela Jones Michelle Williams Sarah Norman David Howells Shelagh Reynolds Joy McRae Bethan Davies Nathan Lester Sally Greenway Heidi Rosenberg Jennifer Evans Theresa Duggan Donna Morgan Dale Jessop Aneurin Bevan LHB Aneurin Bevan LHB Aneurin Bevan LHB Cardiff &Vale University LHB Cardiff &Vale University LHB Cardiff &Vale University LHB Cardiff &Vale University LHB Cwm Taf LHB Cwm Taf LHB Cwm Taf LHB Hywel Dda LHB Hywel Dda LHB Hywel Dda LHB Hywel Dda LHB Powys Teaching LHB Powys Teaching LHB Powys Teaching LHB Velindre NHS Trust Velindre NHS Trust WCISU WCISU WCISU Public Health Wales Welsh Assembly Government NWIS NWIS 3M 3M 3M CCCN 2011/01 Page 10 of 10