ACHIEVING EXCELLENCE IN ABSTRACTING: LYMPHOMA

ACHIEVING EXCELLENCE IN ABSTRACTING: LYMPHOMA

ACHIEVING EXCELLENCE IN ABSTRACTING LYMPHOMA Recoding Audit Performed in 2009 260 cases audited 17 data items audited per case 4420 possible discrepancies 281 Discrepancies identified Overall Accuracy Rate: 93.1% Accuracy Rate Goal: 97%

ACHIEVING EXCELLENCE IN ABSTRACTING LYMPHOMA Problematic Data Items 76.9% of all discrepancies occurred among four data items CS Site Specific Factor #1 (HIV Status) Primary Site (including subsite) CS Extension CS Site Specific Factor #2 (B symptoms)

ACHIEVING EXCELLENCE IN ABSTRACTING LYMPHOMA Excellence can be achieved by concentrating on three areas: 1. Text documentation 106 discrepancies the result of no text support 38 % of all discrepancies Impacted CS Site Specific Factor #1 and #2

ACHIEVING EXCELLENCE IN ABSTRACTING LYMPHOMA 2. Anatomy Lymph node chains above or below the diaphragm Retropharyngeal vs. Retroperitoneal 3. Coding CS Extension Coding bone marrow involvement Coding single vs. multiple lymph node chains Coding lymph node involvement on both sides of the diaphragm Coding lymph nodes with extra lymphatic organ/site involvement

LYMPH NODE LOCATION AND TERMINOLOGY

LYMPH NODE CHAINS ABOVE AND BELOW THE DIAPHRAGM Lymph Nodes Above The Diaphragm Waldeyer s Ring Cervical/Supraclavicular/Occipital/Preauricular Infraclavicular Axillary/Pectoral Mediastinal Hilar Epitrochlear/Brachial Graphic: Clinical Oncology a multidisciplinary approach, 7th ed. (P. Rubin) Lymph Nodes Below The Diaphragm Spleen Mesenteric Para aortic Iliac Inguinal/Femoral Popliteal Northern - CCRA CTR EXAMINATION PREPARATION MANUAL used with permission

LYMPH NODE MAJOR CHAINS OF THE BODY Northern - CCRA CTR EXAMINATION PREPARATION MANUAL used with permission

LYMPH NODES HEAD AND NECK Northern - CCRA CTR EXAMINATION PREPARATION MANUAL used with permission

LYMPH NODES PARIETAL AND VISCERAL Parietal: near the walls of a body cavity Visceral: central within a body cavity Northern - CCRA CTR EXAMINATION PREPARATION MANUAL used with permission

LYMPH NODES LARGE INTESTINE AND LOWER ABDOMEN Northern - CCRA CTR EXAMINATION PREPARATION MANUAL used with permission

LYMPH NODES ABDOMEN AND PELVIS Northern - CCRA CTR EXAMINATION PREPARATION MANUAL used with permission

LYMPHATIC SYSTEM

LYMPHATIC ORGANS Lymphatic Organs Tonsils Palatine Tonsils Lingual Tonsils Pharyngeal tonsil or adenoids Spleen Thymus The whole group of tonsils are known as Waldreyer s ring

LYMPHATIC ORGANS Lymphatic Organs (continued) Other lymphatic tissue Peyer s patches of the small intestine Lymphoid nodules in the appendix Lymphoid nodules in the lamina propria of the tissue that lines the gastrointestinal, respiratory, reproductive, and urinary tracts Bone Marrow

EXTRALYMPHATIC Extralymphatic Lymphoid tissue in solid organs Most common organs with lymphoid tissue Stomach Small intestine Large intestine Bone Uterus Breast Brain

EXTRALYMPHATIC EXTRANODAL Definition of extralymphatic and extranodal Extralymphatic Originating in tissue or an organ that is not part of the lymphatic system Extranodal Originating in any lymphatic system organ other than lymph nodes

ABSTRACTING COACH

ABSTRACTING COACH: DOCUMENTATION Documentation Volume 1, Section 1.6.3 Coding Codes must be supported by text documentation on the abstract.

ABSTRACTING COACH: DOCUMENTATION SSF 1 (HIV/AIDS) Codes 001 (present) and 002 (not present) Must be supported by text documentation SFF 2 (Systemic Symptoms) Codes 000 ( No B Symptoms) Must be supported by text documentation Codes 010-030 ( B Symptoms, pruritis) Must be supported by text documentation

ABSTRACTING COACH: PRIMARY SITE - NODAL VS EXTRANODAL If it is possible to determine where the disease originated, code the primary site to that lymph node chain. Example: Lymphoma is present in the axillary lymph nodes. All other workup is negative for lymphoma. Code primary site to, axillary lymph nodes, C77.3

ABSTRACTING COACH: PRIMARY SITE - NODAL VS EXTRANODAL When multiple lymph node chains are involved at the time of diagnosis, do not simply code the lymph node chain that was biopsied If multiple lymph node chains are involved and it is not possible to determine the lymph node chain where the disease originated, code the primary site to C778, lymph nodes of multiple regions.

ABSTRACTING COACH: PRIMARY SITE - NODAL VS EXTRANODAL If the primary site is unknown or not given: Code retroperitoneal lymph nodes if described as retroperitoneal mass, C77.2 Code inguinal lymph nodes if described as inguinal mass, C77.4 Code mediastinal lymph nodes if described as mediastinal mass, C77.1 Code mesenteric lymph nodes if described as mesenteric mass, C77.2 If the primary site is unknown code Lymph Nodes NOS, C779

ABSTRACTING COACH: PRIMARY SITE - NODAL VS EXTRANODAL If a lymphoma is extranodal, code the organ of origin. Example: Pathology from stomach resection shows lymphoma. No other pathologic or clinical disease identified. Code the primary site as stomach, NOS (C169).

ABSTRACTING COACH: PRIMARY SITE - NODAL VS EXTRANODAL If a lymphoma is present both in an extranodal site and in that organ s regional lymph nodes, code the extralymphatic organ as the primary site. The only exception would be if the lymphoma in the extranodal site were a direct extension from the regional nodes. Lymphomas can spread from the regional lymph nodes into an extranodal site only by direct extension. Example 1: Lymphoma is present in the spleen and splenic lymph nodes. Code the primary site to spleen (C422). Example 2: Lymphoma is present in the stomach and the gastric lymph nodes. Code the primary site to stomach, NOS (C169).

ABSTRACTING COACH: PRIMARY SITE - NODAL VS EXTRANODAL If the lymphoma is present in extralymphatic organ(s) and non-regional lymph nodes, consult the physician to determine a primary site. If a site cannot be determined, code Lymph Node, NOS (C779).

ABSTRACTING COACH: CS EXTENSION Coding Collaborative Stage Extension Four areas of concern Coding single vs. multiple lymph node chains Coding lymph nodes above and below the diaphragm Coding lymph nodes with extralymphatic involvement Coding bone marrow involvement

ABSTRACTING COACH: CS EXTENSION Hint: Use Physician Ann Arbor Staging as a Guide

CS EXTENSION SINGLE VS. MULTIPLE LYMPH NODE CHAINS Example of One Lymph Node Chain Neck US: Right anterior cervical lymphadenopathy Chest CT: Enlarged right anterior cervical lymph node. No disease in thorax. Abd/pelvic CT: NED. Cervical lymph nodes, C77.0 CS Extension code 10, one lymph node chain

CS EXTENSION SINGLE VS. MULTIPLE LYMPH NODE CHAINS Example of Two Lymph Node Chains CT NECK: diffuse mediastinal lymph node enlargement and large left neck mass Pathology: cervical mass: Classical Hodgkin Lymphoma, mixed cellularity subtype Mediastinal lymph nodes, C77.1, and cervical lymph nodes, C77.0, are two separate lymph node chains. CS Extension code 20, two separate lymph node chains on same side of diaphragm

CS EXTENSION MULTIPLE LYMPH NODE CHAINS Example of Muliple Lymph Node Chains CT Thorax: Mediastinal, pericardial left axillary, and retrocural lymphadenopathy. Extensive gastrohepatic ligament, porta caval and retroperitoneal lymphadenopathy. The combination of findings most consistent with lymphoma. CS Extension Code 30, multiple lymph node chains on both sides of the diaphragm

CS EXTENSION LYMPH NODES PLUS EXTRALYMPHATIC SITE Example of Lymph Nodes + Extralymphatic Site CT: soft tissue density noted on anterior aspect of right nostril unclear etiology. Prominent lymph node submandibular region. Enlarged lymph nodes bilateral cervical region at level II-A. Pathology: Soft tissue, right anterior nostril Marginal zone B-cell lymphoma (MALT lymphoma) CS Extension, Code 21, submandibular and cervical lymph nodes, C77.0 plus extralymphatic site on same side of diaphragm

CS EXTENSION BONE MARROW INVOLVEMENT Example of Bone Marrow Involvement CT: widespread lymphadenopathy above and below the diaphragm. There are bulky soft tissue masses surrounding the left external iliac artery. Peripheral blood invovlement does not prove Stage IV Pathology: Supraclavicular lymph node bx: follicular Lymphoma, mixed small & large cells, progressing into diffuse Lymphoma. Bone Marrow: lymphomatous involvement. CS Extension, Code 80, lymph nodes on both sides of diaphragm with bone marrow involvement

ABSTRACTING CHECK LIST Codes must be supported by text documentation on the abstract Consult anatomy illustrations for names of lymph node chains Do not confuse retropharyngeal lymph nodes (C77.0) with retroperitoneal lymph nodes (C77.2) When multiple lymph node chains are involved at the time of diagnosis, do not simply code the lymph node chain that was biopsied

ABSTRACTING CHECK LIST Use references to determine which tissues are extranodal and which are extralymphatic Code the description of mass to the appropriate lymph node chain Read the Collaborative Stage Extension code descriptions carefully Remember to capture bone marrow involvement

WHAT S NEW? LYMPHOMA CSV2

LYMPHOMA SCHEMA CS Tumor Size CS Lymph Nodes CS Mets at Dx 988 Not Applicable 988 Not Applicable 988 Not Applicable CSv1 888 is CSv2 988

LYMPHOMA SCHEMA CS EXTENSION Extension No code changes Extension codes are in 3 groups and are based on primary site

LYMPHOMA SCHEMA CS EXTENSION CODES Nodal/ Lymphatic Extranodal/ Extralymphatic Spleen (involvement) 100 110 120* 200 210 220, 230 300 310 320, 330 800 800 800 999 999 999

LYMPHOMA SCHEMA CS EXTENSION Nodal The following primary site codes are ALWAYS nodal C77.0-C77.9 Lymph nodes C37.9 Thymus Applicable extension codes 100, 200, 300, 800, 999

LYMPHOMA SCHEMA CS EXTENSION Nodal Spleen Lymphatic structure with own set of codes Applicable codes: 120, 220, 230, 320, 330, 800, 999 Spleen Involvement Enlarged spleen on CT is not an indication of involvement Nodules on the spleen must be noted; nodules on spleen are considered involvement

LYMPHOMA SCHEMA CS EXTENSION Nodal/Extranodal The following primary site codes can be nodal or extranodal C02.4 Lingual Tonsil C09.0 C09.9 Tonsil C11.1 Posterior wall of nasopharynx Pharyngeal tonsil C14.2 Waldreyers Ring

LYMPHOMA SCHEMA CS EXTENSION Nodal/Extanodal The following primary site codes can be nodal or extranodal (continued) C17.2 Ileum Documentation MUST state Peyer s patches to be coded as nodal C18.2 Appendix Documentation MUST state nodules in appendix to be coded as nodal

LYMPHOMA SCHEMA CS EXTENSION Remaining primary site codes Coded as extranodal Applicable codes: 110, 210, 310, 800, 999

LYMPHOMA SCHEMA SSF #1 Associated with HIV/AIDS Required by SEER and CoC since CSv1 No changes for CSv2 Code 002 (No/not present) Statement of HIV negativity needed Code 999 (Unknown) Codes must have text documentation! No documentation on HIV status

LYMPHOMA SCHEMA SSF #2 Systemic symptoms at diagnosis Required by SEER and CoC since CSv1 No changes for CSv2 Code 000 (No B symptoms, asymtomatic ) No mention of B symptoms on physical exam Review of systems within normal limits Codes must have text documentation!

LYMPHOMA SCHEMA SSF #3 International Prognostic Index (IPI) Do not try to compute score Required by SEER and CoC since CSv1 Primarily for B-cell lymphomas New codes added: Low risk Intermediate risk High risk Index/Score MUST be documented by physician

LYMPHOMA SCHEMA SSF #4 AND #5 Not required by any standard setters!

CONTINUING EDUCATION INFORMATION To receive CEU hours submit the short Lymphoma Module Quiz located on the CCR website at www.ccrcal.org under Registrars Resources and email it to Katheryne Vance, BA, CTR, Education and Training Coordinator, kvance@ccr.ca.gov

ACKNOWLEDGEMENTS California Cancer Registrars Association, CTR Exam Preparation Manual National Cancer Institute, SEER Program