EVERYTHING YOU WANTED TO KNOW ABOUT. Robin Billet, MA, CTR, Head & Neck CTAP Member May 9, 2013

EVERYTHING YOU WANTED TO KNOW ABOUT. Robin Billet, MA, CTR, Head & Neck CTAP Member May 9, 2013

Head and Neck Coding and Staging

Head and Neck Coding and Staging Anatomy & Primary Site Sequencing and MPH Rules Staging Treatment

Primary Site and Anatomy

Coding the Primary Site, MPH p. 17-18 Code the site where the tumor originated; do not simply code the biopsy site. When there are multiple biopsies and the primary site is not documented, or when there is discrepant information, code the primary site using the following priority order. Priority Order 1. Tumor board a. Specialty b. General 2. Staging physician s site assignment a. AJCC staging form b. TNM statement in medical record If neither 1 nor 2 are available, the priority order for using information depends upon whether the patient had a surgical resection of the primary tumor. 3. Total (complete) resection of primary tumor Note: The primary tumor is completely removed. The surgical margins may be microscopically positive. a. Surgeon s statement from operative report b. Final diagnosis from pathology report

4. No resection (biopsy only): Documentation from: a. Endoscopy (physical exam with scope) b. Radiation oncologist c. Diagnosing physician d. Primary care physician e. Other physician f. Radiologist impression from diagnostic imaging g. Physician statement based on physical exam (clinical impression)

Imaging Techniques CT Scan PET Scan- What is FDG & SUV? MRI Scope http://www.diffen.com/difference/ct_scan_vs_pet_scan

Know Your Anatomy!

C01.9 C02.4 C02.0 C02.3 C02.1

Scenario Physical exam notes ulcerative lesion rt lat tongue. CT scan shows 2 cm mass rt lat border of tongue extending to floor of mouth. Laryngoscopy findings: 2.4 cm lesion originating in the base of tongue extending along the border of the oral tongue to the floor of mouth. What is the primary site? A. C02.1, tip or border of tongue B. C02.3, anterior two thirds of tongue C. C01.9, base of tongue

Scenario PE notes ulcerative lesion rt lat tongue. CT scan shows 2 cm mass rt lat border of tongue extending to floor of mouth. Laryngoscopy findings: 2.4 cm lesion originating in the base of tongue extending along the border of the oral tongue to the floor of mouth. What is the primary site? C. C01.9, base of tongue Scope takes priority over other imaging procedures when there is no resection of the primary site.

Scenario PET scan shows oropharyngeal mass extending from the glossotonsillar sulcus to soft palate Scope shows tumor arising from rt buccal mucosa extending to soft palate Bx soft palate reveals malignancy of minor salivary gland origin What is the primary site?

Scenario C060, rt buccal mucosa ICD-O3, p. 33 Neoplasms of minor salivary glands can be found anywhere in oral cavity & neighboring organs. Ignore minor salivary gland and code to site of origin.

Sequencing & MPH Rules Rules M3-5- Multiple tumors in paired sites, or sites that are upper vs lower (upper lip vs lower lip) are multiple primaries. Rule M6- Multiple tumors in nasal cavity, C30.0 and middle ear, C30.1 are multiple primaries. Rule M7- Multiple tumors that differ at the 2 nd or 3 rd character (Cxxx, Cxxx) are multiple primaries.

Sequencing & MPH Rules Rule M8- An invasive tumor following an in situ tumor more than 60 days is a new primary. Rule M9- Multiple tumors diagnosed more than 5 years apart are multiple primaries. Rule M11- Multiple tumors with histology codes that differ at the first, second, or third character are multiple primaries.

Scenario Pt presents for 6 month follow up of right maxillary retromolar trigone scc s/p excision bx with clear margins. Pt being followed by surveillance scans. Imaging shows new lesion anterior floor of mouth. Excision bx+ for scc. Margins clear. How many primaries? Primary Site?

Scenario Pt presents for 6 month follow up of right maxillary retromolar trigone scc s/p excision bx with clear margins. Pt being followed by surveillance scans. Imaging shows new lesion anterior floor of mouth. Bx+ for scc. How many primaries? 2 Primary Site? C06.2, C04.0

MPH Histology Reminder Code histology from the most representative specimen. Example: Bx of floor of mouth tumor reveals pd keratinizing squamous cell carcinoma. Resection of floor of mouth pathology shows 1.8 cm conventional md squamous cell carcinoma anterior floor of mouth. What is primary site, histology, and grade?

MPH Histology Reminder Code histology from the most representative specimen. Example: Bx of floor of mouth tumor reveals pd keratinizing squamous cell carcinoma. Resection of floor of mouth pathology shows 1.8 cm conventional md squamous cell carcinoma anterior floor of mouth. Primary site- C04.0, anterior floor of mouth Histology- 8070, conventional scc Grade 3, poorly differentiated

Staging

Per CS V02.04 If information in the medical record is ambiguous or incomplete regarding the extent to which the tumor has spread, the extent of disease may be inferred from the T category stated by the physician. Part 1 Section 1, p. 36

Example CT scan shows vocal cord tumor with features highly suggestive of extension to the vallecula. Rad onc stages T4a. What is best CS extension code? a. 775, stated as T4a b. 600, extension to the vallecula

Example CT scan shows vocal cord tumor with features highly suggestive of extension to the vallecula. Rad onc stages T4a. What is best CS extension code? a. 775, stated as T4a b. 600, extension to the vallecula

Pathologic Evaluation The definition of pathologic evaluation includes evaluation based on evidence acquired before treatment, supplemented or modified by the additional evidence acquired during and from surgery, particularly from pathologic examination of the resected specimen. Collaborative Analysis

Example Patient presents for radiation consult s/p resection of upper gum tumor with path showing a 4 cm squamous cell carcinoma of the upper gum with clear margins. Op note observed likely involvement of the genioglossus muscle of the tongue. Path rpt not available for review. Rad onc stages as T4aN0M0. What is best CS extension? A. 775, stated as T4a B. 720, extension to genioglossus muscle of tongue

Example Patient presents for radiation consult s/p resection of upper gum tumor with path showing a 4 cm squamous cell carcinoma of the upper gum with clear margins. Op note observed likely involvement of the genioglossus muscle of the tongue. Path rpt not available for review Rad onc stages as T4aN0M0. What is best CS extension? B. 720, extension to genioglossus muscle.

CS Lymph Nodes

Lymph Node Resource CSV02.04, Part 1, Section 2, p. 29-30 Detailed listing of named lymph nodes and level placement

Lymph Node Structure The code structure for CS Lymph Nodes for head and neck cancers varies by primary site, but in general, the following code ranges apply: 100-190 Single positive ipsilateral nodes involved 200-290 Multiple positive ipsilateral nodes 300-320 positive ipsilateral, unk if 1 or more 400-490 Bilateral or contralateral positive nodes 500-520 Regional nodes, nos, unk # & laterality 800- Lymph Nodes, nos

Inferring Lymph Nodes If the information in the medical record is ambiguous or incomplete regarding the extent to which lymph nodes are involved, lymph node involvement may be inferred from the N category stated by the physician. If there is a discrepancy between documentation in the medical record and the physician s assignment of TNM, the documentation takes precedence. CSV02.04, Part 1, Section 1, p.46

Scenario Imaging studies for staging of epiglottic cancer shows enlarged bilateral cervical lymph nodes. There is a 3 cm left level lll lymph node & 2.4 cm left level ll lymph node suspicious for mets. Rad onc stages N2c. What is best CS lymph node code? A. 410, positive bilat or contralat in 110 with or w/out lns in 100 B. 490, Stated as N2c

Scenario Imaging studies for staging of epiglottic cancer shows enlarged bilateral cervical lymph nodes, 3 cm left level lymph node & 2.4 cm left level 2 lymph node suspicious for mets. Rad onc stages N2c. What is best CS lymph node code? A. 410- CS V02.04 Part 1, Section 1, p. 44

Site Specific Factors SSF 1 Size of lymph nodes SSF 2 Obsolete SSF 3 LN levels I-III SSF 4 LN levels IV, V, & retropharyngeal SSF 5 LN levels VI, VII, & facial SSF 6 Parapharyngeal, parotid, suboccipital, retroauricular lymph nodes SSF 7 Upper vs lower LN levels SSF 8 Clinical Extracapsular Extension SSF 9 Pathologic Extracapsular Extension SSF 10 HPV Status SSF 11 Depth of Invasion SSF s 12-24 Obsolete SSF 25 Nasopharyngeal Subsite

Site Specific Factors Site Specific Factor 1 News Flash

Site Specific Factor 1 Code the largest diameter, whether measured clinically or pathologically, of any involved regional lymph node(s). When enlarged lymph nodes are detected, the actual size of the nodal mass(es) should be measured. Clinical nodal staging is done by size of the palpable mass and should prevail in staging. Coding the larger mass captures furthest extent of disease.

Site Specific Factors 3-7

Site Specific Factors 3-6 Coding Unknown If CS lymph nodes coded 999, then SSF 1 & 3-6 must be coded 999. Lymph Nodes, Nos When the only information available is regional nodes nos, cervical nodes nos, or internal jugular nodes nos, code 000 in SSF 3-6 CSV02.04 Part 1, Section 1, p. 25-26

Scenario Staging CT Scan for base of tongue primary shows extensive bilateral LAD suspicious for mets. What is code for CS lymph nodes? What are codes for SSF 3-6?

Scenario Staging CT Scan for base of tongue primary shows extensive bilateral LAD suspicious for mets. What is code for CS lymph nodes? 400, bilateral cervical, nos What are codes for SSF 3-6? 000

Site Specific Factor 7 Lymph nodes from levels l-lll are upper level nodes Lymph nodes from levels IV & VII are lower level nodes Lymph nodes from level VA are upper, VB are lower, level V, nos, code 040, +lns, unk level Level VI lymph nodes span upper and lower levels

Site Specific Factor 8 Clinical Extracapsular Extension Code 000 if lymph nodes clinically negative. Code 010 if lymph nodes clinically positive, physical exam or imaging documented, and ECE not mentioned Code 030 if documentation only references clinically positive nodes with no available documentation of scans or PE

Site Specific Factor 9 Pathologic Extracapsular Extension Code 000 if lymph nodes negative. Code 010 if path available for review, lns+ and ECE not mentioned. Refer to microscopic and gross descriptions in path report. If ECE+ and no distinction made as to microscopic vs macroscopic code 040. Code 998 for lymph node fna or core bx.

Site Specific Factor 10 HPV Status Do not code HPV Status as positive based on the statement, p16 positive without a statement of HPV positivity. P16 is an antibody whose positivity can be (but not always) associated with HPV virus. This is not the same type of analysis done to assess the high risk type 16 HPV. (per CAnswer Forum)

Site Specific Factors 11 & 25 Site Specific Factor 11 for Select Sites of Lip & Oral Cavity Depth of Invasion Code in tenths of Millimeters; 1 mm coded 010; 1 cm coded 100. SSF 25 for nasopharynx only to derive correct staging algorithm according to subsite.

Treatment Coding Issues

Surgery Capture lymph node bx or fna as treatment; code in scope of regional lns with date coded in surgery date field. Facial nerve dissection not considered sacrifice of facial nerve in parotidectomy. http://www.youtube.com/watch?v=dhw9lm bckog

Radiation Support regional and boost modality with text. Method of delivery takes priority over energies used. VMAT, Volumetric Modulated Arc Therapy is a form of IMRT and should be coded 31. Specify when photons, electrons, or protons are delivered.

Systemic Therapy Cisplatin should be coded as chemotherapy unless specifically stated as a radiosensitizer. Beginning 1/1/2013 Cetuximab/Erbitux will change to BRM, biologic response modifier. Prior to 1/1/13 code as chemo.

References Collaborative Stage Manual V02.04 AJCC Manual, 7 th Ed CAnswer Forum SEER Manuals & Website What Is SUV on a PET Scan? ehow.com http://www.ehow.com/about_6319288_suv-pet-scan_.html#ixzz2quo0jki5 wiki.answers.com... Medical Technologies Radiation Therapy http://www.youtube.com/watch?v=dhw9lmbckog http://www.diffen.com/difference/ct_scan_vs_pet_scan http://www.medilexicon.com/medicalabbreviations.php http://www.rtanswers.org/dictionary/

QUESTIONS?