Bradley W. Schenck, copyright
A CHIEVING E XCELLENCE IN
A BSTRACTING B REAST C ANCER
A CHIEVING E XCELLENCE IN
A BSTRACTING B REAST C ANCER
Recoding Audit Performed in 2009
260 cases audited
17 data items audited per case
4420 possible discrepancies
277 discrepancies identified
Overall Accuracy Rate: 94%
Accuracy Rate Goal: 97%
A CHIEVING E XCELLENCE IN
A BSTRACTING B REAST C ANCER
Problematic Data Items
50% of all discrepancies occurred among five data
items (in descending order):
CS Site Specific Factor #6 (invasive component)
CS Lymph Nodes
Grade
Histology
CS Tumor Size
A CHIEVING E XCELLENCE IN
A BSTRACTING B REAST C ANCER
Excellence Can be Achieved by Concentrating on
Four Areas:
1.
Text documentation
No text documentation
Poor text documentation
Impacted CS Site Specific Factor #6
A CHIEVING E XCELLENCE IN
A BSTRACTING B REAST C ANCER
2.
3.
CS Lymph Nodes
Code 000 versus Code 999
Code 250 versus Code 260
Code 000 versus involved lymph node code
Grade
Volume 1, Section V.3.5.8
Priority for grade when Bloom Richardson is
unknown
A CHIEVING E XCELLENCE IN
A BSTRACTING B REAST C ANCER
4.
Multiple Primary and Histology Rules
H12: Ductal carcinoma and more specific duct
carcinoma
H17: Ductal carcinoma mixed with other types of
carcinoma
A BSTRACTING C OACH
Meet the
Abstracting
Coach
A BSTRACTING C OACH :
D OCUMENTATION
Documentation
Volume 1, Section 1.6.3 Coding
Codes must be supported by
text documentation on the
abstract.
A BSTRACTING C OACH :
SSF 6 – I NVASIVE C OMPONENT
Code indicates how the pathological tumor
size is coded in CS Tumor Size
“Mixed” indicates a tumor with invasive
and in situ components
“Pure” indicates a tumor that contains
only invasive or only in situ components
A BSTRACTING C OACH :
SSF 6 – I NVASIVE C OMPONENT
In Situ Terms
Noninfiltrating
Intraepithelial
Intraductal without infiltration
Lobular neoplasia
Review the Pathology Report Carefully and
Clearly Document Findings
A BSTRACTING C OACH :
SSF 6 – I NVASIVE C OMPONENT
Example of Coding SSF 6
Pathology: Infiltrating ductal carcinoma,
moderately differentiated with extensive
intraductal component; invasive CA measures
0.4 cm.
Code 020 - Both in situ and invasive components
present and size of invasive component is stated.
A BSTRACTING C OACH :
SSF 6 – I NVASIVE C OMPONENT
Example of Coding SSF 6
Mammogram: Spiculated mass in left breast
at 12 o'clock. Ultrasound: 2.2 cm mass highly
suggestive of malignancy.
Code
indicates
path tumor
size
Pathology: Biopsy (+) for infiltrating ductal
carcinoma with aprocine features, and DCIS.
Code 987, Clinical tumor size coded.
A BSTRACTING C OACH :
CS LYMPH N ODES – 000 VS . 999
Inaccessible Lymph Nodes Rule for Regional Lymph Nodes:
For inaccessible lymph nodes, record CS Lymph Nodes
as Code 000 (None) rather than Code 999 (Unknown)
when the following three conditions are met:
1.
There is no mention of regional lymph node
involvement in the physical examination, pretreatment diagnostic testing or surgical exploration.
2.
The patient has clinically low stage (T1, T2, or
localized) disease.
A BSTRACTING C OACH :
CS LYMPH N ODES – 000 VS . 999
3.
The patient receives what would be usual treatment
to the primary site (treatment appropriate to the
stage of disease as determined by the physician) or
is offered usual treatment but refuses it, since this
presumes that there are no involved regional lymph
nodes that would otherwise alter the treatment
approach.
Code 999 can and should be used in situations where
there is reasonable doubt that the tumor is no longer
localized and there is no documentation of involved
regional lymph nodes.
CS Manual, Part 1
A BSTRACTING C OACH :
CS LYMPH N ODES – 000 VS . 999
Example of Coding CS Lymph Nodes 000
PE: Mass in LOQ right breast, no palpable lymph
nodes
Excisional biopsy: Invasive lobular carcinoma, TS;
1.5 cm., margins clear
CS Lymph Nodes: Code 000 – clinically negative
lymph nodes and localized disease
A BSTRACTING C OACH :
CS LYMPH N ODES – 000 VS . 999
Example of Coding CS Lymph Nodes 999
PE: Lungs clear
Left breast biopsy: Lesion at 3:00 position
Pathology: Moderately differentiated infiltrating
ductal and intraductal carcinoma. TS: 0.7 cm
Port-A-Cath placement
CS Lymph Nodes: Code 999, no information regarding
regional lymph nodes, chemotherapy planned
A STRACTING C OACH :
CS LYMPH N ODES – 250 VS . 260
Code 250
Movable axillary lymph node(s), ipsilateral,
positive with more than micrometastasis
Code 260
Stated as N1, NOS
A BSTRACTING C OACH :
CS LYMPH N ODES – 250 VS . 260
Inferring Lymph Node Involvement From Stated
N Category:
Warning!
If the information in the medical record is
ambiguous or incomplete regarding the
extent that the tumor has spread, lymph node
involvement may be inferred from the N category
as stated by the physician. CS Manual, Part 1
Use the physician stated N category only after a
thorough search for more specific information
A BSTRACTING C OACH :
CS LYMPH N ODES – 250 VS . 260
Example of Coding CS Lymph Nodes 250:
Pathology: Infiltrating ductal carcinoma, grade 2,
6/9 points. Axillary sentinel lymph node (+): 1/1.
Axillary lymph nodes(+): 2/6 by IHC.
Tx, N1, M0 = stage 2A per AJCC staging form
CS Lymph Nodes: Code 250, Breast Schema, CS
Lymph Nodes, Note 2. Code 260 is used in cases
in which N1 documented by physician is the only
information available.
A BSTRACTING C OACH :
G RADE
Volume 1, V.3.5.8
Bloom-Richardson Grade for Breast Cancer
Use BR
grade
if available!
Synonyms include:
Modified Bloom-Richardson
Scarff-Bloom-Richardson
Nottingham
SBR Grading
BR Grading
Elston-Ellis modification of Bloom-Richardson
A BSTRACTING C OACH :
G RADE
Use grade or differentiation information from the
breast histology in the following priority order:
Bloom-Richardson (Nottingham) scores 3-9
converted to grade (see conversion table)
Bloom-Richardson grade (low, intermediate, high)
Nuclear grade only
Terminology (well diff, mod diff…)
Histologic grade (grade I, grade ii…)
A BSTRACTING C OACH :
G RADE
Bloom-Richardson Conversion Table
BloomRichardson
Score
3-5
6, 7
8, 9
BloomRichardson
Grade
Low
Intermediate
High
Nuclear
Grade
Term
Histo
Grade
Code
1/3, 1/2
Well
Diff
BR Low
Grade
1
2/3
Mod
Diff
BR
Interm.
Grade
2
2/2, 2/3
Poorly
Diff
BR
High
Grade
3
A BSTRACTING C OACH :
G RADE
In this grading system, the terms low,
intermediate, and high are codes 1, 2, and 3
respectively
In the Bloom-Richardson system, if grades 1, 2,
and 3 are specified, these should be coded 1, 2,
and 3 respectively
CAUTION !
A BSTRACTING C OACH :
G RADE
Example of Coding Grade
Pathology: Needle biopsy. Infiltrating ductal
carcinoma BR score 8/9. Lumpectomy with
sentinel lymph node biopsy and axillary lymph
node dissection; TS 4 cm, high grade infiltrating
ductal carcinoma involving pectoralis muscle;
4/33 axillary lymph nodes positive.
Grade: Code 3, Bloom-Richardson 8/9 = 3, per
Volume 1, Section V.3.5.8
A BSTRACTING C OACH :
G RADE
Example of Coding Grade
Pathology: Lumpectomy. Multiple foci of ductal
carcinoma in invasive cribiform carcinoma, low
grade.
Grade code: Code 2, Volume 1, Section V.3.5;
low grade, NOS = 2
A BSTRACTING C OACH :
H ISTOLOGY - H12 AND H17
Multiple Primary and Histology Rules
H12: Duct carcinoma, NOS and a more specific
duct carcinoma
Specific histology may be identified as:
Type, Subtype
Predominately
With features of, major, or with ___ differentiation
Architecture and pattern (in situ only)
A BSTRACTING C OACH :
H ISTOLOGY – H12 AND H17
Multiple Primary and Histology Rules
H17: Combination of duct and any other
carcinoma
Use Table 2 in MP/H Manual, Breast, to identify
duct carcinomas
Other carcinomas and any duct carcinoma listed
on Table 1 or Table 2
A BSTRACTING C OACH :
H ISTOLOGY – H12 AND H17
Table 1 – Intraductal (8500/2) and Specific Intraductal Carcinomas
Most common specific intraductal carcinomas
Column 1: Code
Column 2: Type
8201
Cribiform
8230
Solid
8401
Apocrine
8500
Intraductal, NOS
8501
Comedo
8503
Papillary
8504
Intracystic
8507
Micropapillary/Clinging
A BSTRACTING C OACH :
H ISTOLOGY – H12 AND H17
Table 2 – Duct (8500/3) and Specific Duct Carcinomas
Most common specific intraductal carcinomas
Column 1: Code
Column 2: Type
8022
Pleomorphic carcinoma
8035
Carcinoma with osteoclast-like giant cells
8500
Duct, NOS
8501
Comedocarcinoma
8502
Secretory carcinoma of breast
8503
Intraductal papillary adenocarcinoma with
invasion
8508
Cystic hypersecretory carcinoma
A BSTRACTING C OACH :
H ISTOLOGY – H12 AND H17
SEER SINQ 20091130
Question:
How are the following two examples coded?
Infiltrating ductal carcinoma, mucinous type
Infiltrating ductal carcinoma with features of
tubular carcinoma
Answer:
The infiltrating ductal types in Rule H12 are listed (8022,
8035, 8501-8508) and do not include mucinous nor tubular.
This rule cannot be applied. The first rule that applies to
these single tumors is H17, code to histology code 8523,
infiltrating duct mixed with other types of carcinoma.
A BSTRACTING C OACH :
H ISTOLOGY – H12 AND H17
SEER SINQ 20091085
Question:
What is the correct histology code for this breast
cancer case?
Final diagnosis says, "Infiltrating duct carcinoma
with apocrine features." What rule is used?
Answer:
Assign histology code 8401/3 (apocrine
adenocarcinoma) according to rule H12. Apocrine is a
type of duct carcinoma (see Table 1). Code 8401
should be listed in Rule H12. Apocrine should be
removed from Table 3.
A BSTRACTING C OACH :
CS T UMOR S IZE
Three Site-Specific Codes:
996 - mammographic/xerographic diagnosis
only, no size given; clinically not palpable
997 - Paget’s Disease of nipple with no
underlying tumor
998 - diffuse
A BSTRACTING C OACH :
CS T UMOR S IZE
Neoadjuvant Treatment Planned or Administered
If the patient receives preoperative (neoadjuvant)
systemic therapy (chemotherapy, hormone therapy,
immunotherapy) or radiation therapy, code the farthest
involved regional lymph nodes based on information
prior to surgery. CS Manual, Part 1
Example: Patient has a hard matted mass in the axilla
(code 510) and a needle biopsy of the breast that
confirms ductal carcinoma. Patient receives three
months of chemotherapy. The pathology report from
the modified radical mastectomy shows only scar tissue
in the axilla with no involvement of axillary lymph nodes
(Negative, code 000).
Code CS Lymph Nodes as 510 because prior to treatment they
appeared to be clinically involved.
A BSTRACTING C OACH :
CS T UMOR S IZE
Example of Coding CS Tumor Size
PE: Left breast, at 2:00 a 2.8 cm malignant appearing
mass.
Pathology: Biopsy. Infiltrating ductal carcinoma,
suspicious for lymphatic invasion.
Pre Surgery Chemotherapy
Pathology: Segmental mastectomy. Infiltrating ductal
carcinoma small cell subtype, grade 2, tumor size 1.5
cm. Ductal carcinoma, solid type, tumor size 2.0 cm.
Margins clear. Chemotherapy effect present.
A BSTRACTING C OACH :
CS T UMOR S IZE
Example of Coding CS Tumor Size (continued)
CS Tumor Size, code 028, clinical tumor size.
CS Manual, Part 1, states, “If the patient
receives preoperative (neoadjuvant) systemic
therapy (chemotherapy, hormone therapy,
immunotherapy) or radiation therapy, code
the farthest involved regional lymph nodes
based on information prior to surgery.”
A BSTRACTING C OACH :
CS T UMOR S IZE
Example of Coding CS Tumor Size (continued)
Pathology: Needle core biopsies of calcifications –
microscopic foci of in situ ductal carcinoma
CS Tumor Size, code 990; microscopic focus or foci
only. CS Manual, Part 2, Breast schema, CS Tumor
Size
A BSTRACTING C OACH :
CS T UMOR S IZE
Example of Coding CS Tumor Size (continued)
Mammogram and magnified views: 1 cm solid nodule
left breast at 2:00; no other findings
Specimen radiograph confirms successful excision.
Palpable mass in middle of specimen
Pathology: Lobular carcinoma in situ with Pagetoid
spread into duct
CS Tumor Size, code 010. No tumor size mentioned
on pathology, use radiography tumor size
C OACH ’ S A BSTRACTING
C HECKLIST
C OACH ’ S A BSTRACTING
C HECKLIST
Code selected for SSF #6 is related to the
pathological tumor size for CS Tumor Size
Follow the inaccessible lymph node rule in the
CS Manual, Part 1, when regional lymph nodes
are not removed
Use the physician stated N category only after a
thorough search for more specific information
Follow Volume 1, V.3.5.8 when coding grade
C OACH ’ S A BSTRACTING
C HECKLIST
In coding histology, rule H12 is applied when
there is a duct carcinoma, NOS and a more
specific duct carcinoma
In coding histology, rule H17 is applied when
there is a combination of duct and any other
carcinoma
Apocrine is a type of duct carcinoma, see Table 1.
Code 8401 should be listed in Rule H12. Apocrine
should be removed from Table 3.
C OACH ’ S A BSTRACTING
C HECKLIST
SEER
Program
Coding
And Staging
Manual
C OACH ’ S A BSTRACTING
C HECKLIST
C50.0 Nipple (areolar)
Paget disease without underlying tumor
C50.1 Central portion of breast (subareolar) area
extending 1 cm around areolar complex
Retroareolar, Infraareolar
Next to areola, NOS
Behind, beneath, under, underneath, next to,
above, cephalad to, or below nipple
Paget disease with underlying tumor
C OACH ’ S A BSTRACTING
C HECKLIST
C50.2 Upper inner quadrant (UIQ) of breast
Superior medial
Upper medial
Superior inner
C50.3 Lower inner quadrant (LIQ) of breast
Inferior medial
Lower medial
Inferior inner
C OACH ’ S A BSTRACTING
C HECKLIST
C50.4 Upper outer quadrant (UOQ) of breast
Superior lateral
Superior outer
Upper lateral
C50.5 Lower outer quadrant (LOQ) of breast
Inferior lateral
Inferior outer
Lower lateral
C OACH ’ S A BSTRACTING
C HECKLIST
C50.6 Axillary tail of breast
Tail of breast, NOS
Tail of Spence
C OACH ’ S A BSTRACTING
C HECKLIST
C50.8 Overlapping lesion of breast
Inferior breast, NOS - Inner breast, NOS
Lateral breast, NOS - Lower breast, NOS
Medial breast, NOS - Midline breast NOS
Outer breast NOS - Superior breast, NOS
Upper breast, NOS
3:00, 6:00, 9:00, 12:00 o’clock
C OACH ’ S A BSTRACTING
C HECKLIST
When to Use Subsite 8:
Code the Primary Site to C50.8 when:
There is a single tumor that overlaps two or
more subsites, and the subsite in which the
tumor originated is unknown
There is a single tumor located at the 12, 3, 6,
or 9 o’clock position on the breast
C OACH ’ S A BSTRACTING
C HECKLIST
When to Use Subsite 9:
Code the Primary Site to C50.9 when:
There are multiple tumors (two or more) in at
least two quadrants of the breast
There are multiple tumors (two or more) in at
least two quadrants of the breast
There is inflammatory carcinoma without
palpable mass
C ONTINUING E DUCATION
I NFORMATION
To Receive CEU Hours:
Complete the short Breast Module Quiz located
at:
http://www.classmarker.com/embedded_quizzes
/?quiz=f65840869ba31a35dd56c66352849b74
Copy entire address into your web browser
This is an external web site, quiz results will be
automatically emailed to Katheryne Vance, BA,
CTR, Education and Training Coordinator
A CKNOWLEDGEMENTS
National Cancer Institute, SEER Program
Cover art by Bradley W. Schenck, copyright used with
permission