coding pitfalls jessica k. dohler, bs, ctr. objectives 0 know how to code the tumor/ext eval code...

Coding PitfallsJessica K. Dohler, BS, CTR

Objectives

0Know how to code the Tumor/Ext Eval code when using intraoperative findings

0Know when to code “none” vs. “unknown” by using the Inaccessible LN Rules

0Understand the 2012 FORDS Grading guidelines changes

0Understand the limitations of imaging in prostate staging

TS/Ext Eval 1 or 3Is information on an operative report TS/Ext eval code 1 or 3?

TS/Ext Eval 1 or 3Eval Code Choices for OP Findings

Eval Code 1 - Clinical Eval Code 3 - Pathologic

0No surgical resection done.

0 Invasive techniques or surgical observation without biospy

0Surgical resection performed without neoadjuvant txt

0Based on evidence acquired before txt supplemented or modified by evidence acquired during & from surg

TS/Ext Eval 1 or 3Scenario – Exam and Op

Findings0CT of abdomen & colonoscopy negative

0Operative findings – sigmoidectomy & right oophorectomy• Bulky colon mass extends into

retroperitoneum• Peritoneal seeding• Thickened and suspicious right ovary

TS/Ext Eval 1 or 3Scenario – Pathology Report

0Sigmoid colon and upper rectum• Signet ring cell adenocarcinoma, high grade• Invades through muscularis propria into subserosal

fat• Proximal & distal margins negative• Radial margins, positive/involved

0Ovary – negative for tumor0Path staging • pT3 pN2a• 5/21 LN involved

TS/Ext Eval 1 or 3Summary: Op Findings vs. Path Report

0Op Findings• Tumor extends outside colon into retroperitoneum• CS Ext code 675, maps to T4b

0Path Report • Subserosal fat, radial margin positive• CS Ext code 400, maps to T3 (also stated by

pathologist)

Which takes precedence?

TS/Ext Eval 1 or 3Eval Code Choices for OP Findings

Eval Code 1 - Clinical Eval Code 3 - Pathologic

0No surgical resection done.

0 Invasive techniques or surgical observation without biospy

0Surgical resection performed without neoadjuvant txt

0Based on evidence acquired before txt supplemented or modified by evidence acquired during & from surg

TS/Ext Eval 1 or 3What Eval Code to Use?

0We know to code the extension to 675 since it is the most extensive

0Eval code 1 since info is from the op findings (observation during surgery)?

0Eval code 3 since there was a resection done?

TS/Ext Eval 1 or 3Scenario Answer

0Correct eval code is 3 – pathologic0Rationale• Supplemented/modified by evidence aquired during

and from surgery• Use information from op findings since nothing in path

overrides this information• Pathologist did not receive any tissue for the

retroperitoneumNOTE: op findings without surgical resection

would be eval 1.

TS/Ext Eval 1 or 3References

0CS v0204 Coding Instructions• Part I Section 1, page 41•#7 – Explanation of code 1•#8 – Explanation of code 3

Inaccessible Lymph Nodes

Coding “None” vs. “Unknown”

Inaccessible Lymph NodesWhat are they?

0Inaccessible lymph nodes are those that cannot be easily examined during a physical exam or observation.

0They are located within body cavities and cannot be palpated.

0Some primary sites with inaccessible lymph nodes• Bladder, colon, uterus, lung, liver, ovary,

kidney, prostate and stomach

Inaccessible Lymph NodesWhat’s the rule?

0Move to code “none” rather than “unknown.”0Three conditions must be met:• No mention of regional LN involvement on

PE, imaging or surgical exploration• Patient has clinically low stage (T1,T2 or

localized) disease.• Patient receives or is offered the usual

treatment for node negative primary site disease.

Inaccessible Lymph NodesScenarios

084 y/o male has 2.2cm LUL mass on CT, LN not mentioned.

0CT guided needle biopsy positive for adenoca.0Patient not a surgical candidate due to comorbidities.0Patient received steriotactic surgery to LUL mass only.

No chemo recommended.

Do you code CS LN to 000 or 999?• Correct answer = 000


069 y/o male with elevated PSA at 4.9.0DRE WNL0Prostate bx shows adenocarcinoma in 2/12 cores.

Gleason score 3+3=6.0MD stages T1c0Patient undergoes prostate seed brachytherapy

radiation alone.



058 y/o female with chest pain and shortness of breath.

0CT shows a 9.2cm mass in the RUL, no mention of LN.0CT guided biopsy of mass positive for SQCCA.0Patient receives radiation and refuses chemo.



062 y/o male with elevated PSA at 36.2.0DRE WNL0Prostate bx shows adenocarcinoma in 6/12 cores

with extracapsular extension. Gleason score 3+3=6.0Patient undergoes prostate seed brachytherapy

radiation and hormone therapy.


Inaccessible Lymph NodesReferences

0CS v0204 Coding Instructions• Part I Section 1, page 5 – Documenting

Negative Lymph Nodes and Distant Metastases• Part I Section 1, page 21 – Inaccessible

Lymph Nodes Rule

Grade Differentiation

2012 Changes

Grade Differentiation 2012 Changes

0Entire Morphology: Grade section of FORDS has been changed

0Jan 2012 Cases – CoC no longer supports site specific grade conversion

0SSF grading fields take precedence0Hierarchy of guidelines for coding morphology

grade differentiation

Grade Differentiation Guidelines

1. Hematopoietic and Lymphatic Grades

• Code in Grade/Differentiation field • All must be coded to 5-8 or 9• Code according to Hematopoietic and

Lymphoid Neoplasm Case Reportability and Coding Manual• Leave Grade Path System and Grade Path Value

fields blank


2. Special Grades

• Code in Collaborative Staging SSF fields• Code all SSF grade fields according to specific CS

instructions in CS Manual Part 1 Section 2• Gleason, Furhman, WHO, Nottingham or Bloom-

Richardson• Code Grade/Differentiation field as 9• Leave Grade Path System and Grade Path Value fields

blank


3. Grade Path System and Grade Path Value

• Other than hematopoietic and lymphatic or special grade• Documented in numeric form AND number of

grades in system known• DO NOT convert verbal description to numeric

codes• Code Grade/Differentiation field as 9


4. All Others

• Grade cannot be coded according to rules 1 through 3

• See table on page 12-13 of FORDS for complete list of verbiage/code conversion

Grade DifferentiationScenarios

0LN Bx: Follicular lymphoma, grade 2• Look in Hematopoeitic

Database

Grade/Differentiation = 6Grade Path System = BlankGrade Path Value = Blank


0Prostate Bx: Adenocarcinoma in 5/12 cores. Gleason 4+3=7.

Grade/Differentiation = 9Grade Path System = BlankGrade Path Value = BlankProstate SSF 7 = 043Prostate SSF 8 = 007


0TURB: High Grade Urothelial Carcinoma In Situ

Grade/Differentiation = 9Grade Path System = BlankGrade Path Value = BlankBladder SSF 1 = 020

Per notes assume term high grade is a WHO Grade


0Sigmoid Colon Bx: Adenocarcinoma. Grade 2 of 2.

Grade/Differentiation = 9Grade Path System = 2Grade Path Value = 2


0Breast Lumpectomy: Well differentiated ductal carcinoma. Bloom-Richardson score 4. Nuclear Grade 1/3.

Grade/Differentiation = 1Grade Path System = 3Grade Path Value = 1Breast SSF 7 = 040

Grade DifferentiationReferences

0FORDS 2012 Manual • Section One – Overview of Coding Principles

Morphology: Grade, Pgs 10-13

Prostate ImagingCan I use imaging to determine if cancer is apparent or inapparent?

Prostate ImagingInapparent vs.

Apparent0DRE – gold standard for staging• Used to determine inapparent (not felt) or apparent

(felt)0 Imaging – TRUS, MRI, CT• Not used for staging unless managing physician

confirms• Not used due to limitations (too often results incorrect)• Interobserver variability• Lack of sensitivity and specificity

Prostate ImagingCS Extension Table Notes &

Clarification Note 3A:0A clinically apparent tumor is palpable or visible by

imaging.• Clarification: No list of words for imaging that determine

if visible. Only the clinician/managing physician can interpret.

0 If a clinician documents a "tumor", "mass", or "nodule“, this can be inferred as apparent.• Clarification: CS got permission to use these words for the

clinician, which only applies to the DRE. The words cannot be used for imaging.

Prostate ImagingCoding Scenarios

Patient has an elevated PSA and benign DRE per MD note. MRI report states the result as T2c. No managing MD stage. What is the CS Extension code?

0CS Extension Code = 150 • Since there is no managing MD stage the MRI report was

not supported by the managing physician. Therefore code 150 . Clinically inapparent tumor. Bx done for elevated PSA


Unknown if DRE performed. No documented pre-bx PSA. MRI report states T2a prostate tumor. No managing physician stage. What is the CS Extension code?

0CS Extension Code = 300• Since there is no documented DRE or physician

statement it is unknown why the biopsy was performed. It is unknown if the tumor is apparent or not. Best to use the NOS code.


Elevated PSA. Benign DRE. MRI shows nodule occupying greater than half of left lobe. Managing MD stage is T2. What is the CS Extension Code?

0CS Extension Code = 220• Although the managing MD T stage is T2nos it is safe to

code to cT2b since it is obvious that MD stage is based upon the MRI which specifically shows greater than half of one lobe involved with tumor.

Prostate ImagingReferences

0 CS v0204 Coding Instructions•Part II, Prostate Schema, page 44

THANK YOU!!!!

coding pitfalls jessica k. dohler, bs, ctr. objectives 0 know how to code the tumor/ext eval code...

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