Methods of Reporting Cancer Registry Information

Section 840 Section 840.115  Methods of Reporting Cancer Registry Information a)         All patients identified at a reporting facility, whether as an inpatient or outpatient, who meet one of the three following criteria are reportable to the Registry: 1)         Patients with a newly diagnosed cancer who have, within six months after diagnosis, received cancer-directed treatment or refused treatment. 2)         Patient with cancer diagnosed through autopsy. 3)         Patient diagnosed and receiving all first course treatment elsewhere and now receiving cancer-directed treatment at the reporting facility. b)         A patient is considered to have a malignant neoplasm when a licensed physician or dentist indicates that he/she does.  Otherwise, the following terminology, when applied to a malignancy, shall be interpreted as indicating involvement by a cancerous tumor: 1)         apparent, 2)         appears to, 3)         comparable with, 4)         compatible with, 5)         consistent with, 6)         favors, 7)         malignant appearing, 8)         most likely, 9)         presumed, 10)         probable, 11)         suspected, 12)         suspicious for, and 13)         typical of. c)         The following terminology, when applied to a malignancy without additional information, shall be interpreted as indicating non-involvement by a cancerous tumor: 1)         cannot be ruled out, 2)         equivocal, 3)         possible, 4)         potentially malignant, 5)         questionable, 6)         rule out, 7)         suggests, and 8)         worrisome. d)         Determination of whether or not a given primary tumor is reportable shall be made by reference to the morphology codes (M-codes) of the International Classification of Diseases for Oncology (ICD-O). e)         The specified cases of tumorous or precancerous diseases that shall be reported to the Registry are: 1)         benign intracranial tumors, and 2)         other conditions that the facility wishes to report. f)         Cases of basal or squamous cell neoplasms of the skin shall be reported only when located in the following areas:  penis, scrotum, anus, eyelid, and muco-cutaneous junctions of the lips, labia and vulva. g)         Facilities shall electronically submit the report in the NAACCR data exchange format, using the version specified by the Registry (see Section 840.20).  Supporting text documentation that is sufficient to support the diagnosis, stage and treatment should be included for each case submitted. h)         All reporting facilities are responsible for complete casefinding, which means identifying all first time reported cancer patients and completing an incidence report form for the Registry.  To achieve complete case ascertainment, the following sources should be reviewed as they apply:  Medical Record Disease Index (ICD-CM) or CPT Coding Index; pathology reports; cytology reports; autopsy reports; surgery and/or outpatient logs; radiation therapy and/or oncology clinic logs and appointment books; and diagnostic X-rays, nuclear medicine reports, and/or other imaging techniques. 1)         Any patient's clinical record identified with any of the following ICD-9-CM Diagnosis, ICD-10-CM Diagnosis, or Procedure Codes by the Medical Record Department shall be reviewed for reportability to the Registry: Diagnosis Codes                     Diagnosis (in preferred ICD-O-3 terminology) A)        042                              AIDS with malignancy B)        140.0-208.9                 Malignant neoplasms C)        203.1                           Plasma cell leukemia (9733/3) D)        205.1                           Chronic neutrophilic leukemia (9963/3) E)        225.0-225.4                 Benign intracranial and CNS neoplasms 225.8-225.9 227.3-227.4 F)        230.0-234.9                 Carcinoma in situ G)       237.0-237.1                 Borderline intracranial and CNS neoplasms 237.5-237.6 237.7, 237.9 H)       238.4                            Polycythermia erra (9950/3) I)         238.6                            Solitary plasmacytoma (9731/3) J)         238.6                            Extramedullary plasmacytoma (9734/3) K)       238.7                            Chronic Myeloproliferative disease (9960/3) L)        238.7                            Myelosclerosis with myeloid metaplasia (9961.3) M)       238.7                            Essential thrombocythemia (9962/3) N)       238.7                            Refractory cytopenia with multilineage displasia (9985/3) O)       238.7                            Myelodisplastic syndrome with 5q-syndrome (9986/3) P)        238.7                            Therapy related myelodisplastic syndrome (9987/3) Q)       239.0-239.9                 Neoplasms of unspecified behavior R)        273.2                            Gamma heavy chain disease; Franklin's disease S)        273.3                            Waldenstrom's macroglobulinemia T)        273.9                            Unspecified disorder of plasma protein metabolism (screen for potential 273.3 miscodes) U)       284.9                            Refractory anemia (9980/3) V)       285.0                            Refractory anemia with ringed sideroblasts (9982/3) W)       285.0                            Refractory anemia with excess blasts (9983/3) X)       285.0                            Refractory anemia with excess blasts in transformation (9984/3) Y)       288.3                            Hypereosinophilic syndrome (9964/3) Z)        289.8                            Acute myelofibrosis (9932/3) AA)       V07.8                           Other prophylactic chemotherapy (screen carefully for miscoded malignancies) BB)       V07.8                           Other specified prophylactic measures CC)       V10.0-V10.9               Personal history of malignant neoplasm (review these for recurrences, subsequent primaries and/or subsequent treatment) DD)       V58.0                           Admission for radiotherapy EE)       V58.1                           Admission for chemotherapy FF)       V66.1                           Convalescence following radiotherapy GG)       V66.2                           Convalescence following chemotherapy HH)       V67.1                           Radiation therapy follow-up II)       V67.2                           Chemotherapy follow-up JJ)        V71.1                           Observation for suspected malignant neoplasm KK)        V76-V76.9                  Special screening for malignant neoplasm LL)       92.21-92.29                 Therapeutic radiology and nuclear medicine MM)        92.21-92.29                 Injection or infusion of cancer chemotherapeutic substance NN)        C00-C43, C45-C96     Malignant neoplasms (excluding category  C44), stated or presumed to be primary (of specified site) and certain specified histologies.  (Note:  Pilocytic/juvenile astrocytoma (M-9421) is reported with the behavior coded /3 (i.e., 9421/3 not 9421/1).) OO)       D00-D09                     In-situ neoplasms (Note:  Carcinoma in situ of the cervix (CIN III-8077/2) and Prostatic Intraepithelial Carcinoma (PIN III-8148/2) are not reportable.) PP)        D18.02                         Hemangioma of intracranial structures and any site QQ)      D18.1                           Lymphangioma, any site (Note:  Includes Lymphangiomas of Brain, Other parts of nervous system and endocrine glands, which are reportable.) RR)       D32                              Benign neoplasm of meninges (cerebral, spinal and unspecified) SS)      D33                              Benign neoplasm of brain and other parts of central nervous system (CNS) TT)       D35.2-D35.4               Benign neoplasm of pituitary gland, craniopharyngeal duct and pineal gland UU)       D42-D43                     Neoplasm of uncertain or unknown behavior of meninges, brain, CNS VV)       D44.3-D44.5               Neoplasm of uncertain or unknown behavior of pituitary gland, craniopharyngeal duct and pineal gland WW)      D45                              Polycythemia vera (9950/3) XX)      D46                              Myelodysplastic syndromes YY)      D47.1                           Chronic myeloproliferative disease ZZ)      D47.3                           Essential (hemorrhagic) thrombocythemia (9962/3)) AAA)     D47.4                           Osteomyelofibrosis (9961/3) BBB)     D47.7                           Other specified neoplasms of uncertain/unknown behavior of lymphoid, hematopoietic CCC)     D47.Z                          Other neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue DDD)    D47.9                           Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue unspecified EEE)     D49.6, D49.7               Neoplasm of unspecified behavior of brain, endocrine glands and other CNS FFF)     J91.0                            Malignant pleural effusion GGG)    R18.0                           Malignant ascites HHH)    Z08                              Encounter for follow-up examination after completed treatment for malignant neoplasm III)   Z12                              Encounter for screening for malignant neoplasms JJJ)    Z51.0                           Encounter for antineoplastic radiation therapy KKK)  Z51.1                           Encounter for antineoplastic chemotherapy and immunotherapy LLL)   Z85                              Personal history of malignant neoplasm MMM)   Z86.0, Z86.01,             Personal history of in situ and benign Z86.03                         neoplasms and neoplasms of uncertain behavior NNN)  Z92.21, Z92.23,           Personal history of antineoplastic Z92.25, Z92.3              chemotherapy, estrogen therapy, immunosuppression therapy or irradiation (radiation) OOO)  R85.614                       Cytologic evidence of malignancy on smear of anus PPP)    R87.614                       Cytologic evidence of malignancy on smear of cervix QQQ)  R87.624                       Cytologic evidence of malignancy on smear of vagina 2)         All pathology and cytology reports from the facility with a positive morphologic diagnosis of cancer shall be reviewed for reportable neoplasms, including reports on inpatient and outpatient surgical resections and biopsy specimens, bone marrow biopsies, cytology specimens and autopsies. 3)         Any conflict of interpretation of cancer incidence shall defer to the clinician's determination. i)          All reporting facilities shall submit the report forms on a monthly basis.