CASEFINDING

 

All participating institutions should establish procedures for complete casefinding within their institution. In many hospitals, records are housed in one location (i.e., the medical records department). In others, procedures for identifying patients from multiple independent ancillary service areas may be necessary (i.e., outpatient clinics, radiation therapy, etc). It is important that the following multiple sources in the hospital be searched to keep missed reportable cases to a minimum. The procedures outlined below should be adapted to each individual hospital.

 

1.  Medical record disease discharge diagnostic index:

 

Any patient record coded with the diagnoses listed below should be reviewed to determine if the case is one which meets KCR reportability criteria.  Note that a diagnosis is not necessarily reportable simply because it falls within the codes below; refer to the Case Reportability Requirements to make sure the case is truly reportable to KCR.  

 

ICD-10-CM Codes (Effective 10-01-2015 through 09-30-2016)

 

ICD-10-CM Code

Explanation of ICD-10-CM Code

C00.- - C43.-, C4A.-, C45.- - C96.-

Malignant neoplasms (excluding category C44), stated or presumed to be primary (of specified site) and certain specified histologies

C44.00, C44.09

Unspecified/other malignant neoplasm of skin of lip

C44.10-, C44.19-

Unspecified/other malignant neoplasm of skin of eyelid

C44.20-, C44.29-

Unspecified/other malignant neoplasm skin of ear and external auricular canal

C44.30-, C44.39-

Unspecified/other malignant neoplasm of skin of other/unspecified parts of face

C44.40, C44.49

Unspecified/other malignant neoplasm of skin of scalp & neck

C44.50-, C44.59-

Unspecified/other malignant neoplasm of skin of trunk

C44.60-, C44.69-

Unspecified/other malignant neoplasm of skin of upper limb, incl. shoulder

C44.70-, C44.79-

Unspecified/other malignant neoplasm of skin of lower limb, including hip

C44.80, C44.89

Unspecified/other malignant neoplasm of skin of overlapping sites of skin

C44.90, C44.99

Unspecified/other malignant neoplasm of skin of unspecified sites of skin

 

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

D18.02

Hemangioma of intracranial structures and any site

 

D18.1

Lymphangioma, any site

Note: Includes Lymphangiomas of Brain, Other parts of nervous system and endocrine glands, which are reportable

D32.-

Benign neoplasm of meninges (cerebral, spinal and unspecified)

D33.-

Benign neoplasm of brain and other parts of central nervous system

D35.2 - D35.4

Benign neoplasm of pituitary gland, craniopharyngeal duct and pineal gland

D42.-, D43.-

Neoplasm of uncertain or unknown behavior of meninges, brain, CNS

D44.3 - D44.5

Neoplasm of uncertain or unknown behavior of pituitary gland, craniopharyngeal duct and pineal gland

 

D45

Polycythemia vera (9950/3)

ICD-10-CM Coding instruction note: Excludes familial polycythemia (C75.0), secondary polycythemia (D75.1)

D46.-

Myelodysplastic syndromes (9980, 9982, 9983, 9985, 9986, 9989, 9991, 9992)

 

 

D47.1

Chronic myeloproliferative disease (9963/3, 9975/3)

ICD-10-CM Coding instruction note: Excludes the following: Atypical chronic myeloid leukemia BCR/ABL-negative (C92.2_) Chronic myeloid leukemia BCR/ABL-positive (C92.1_) Myelofibrosis & Secondary myelofibrosis (D75.81) Myelophthisic anemia & Myelophthisis (D61.82)

D47.3

Essential (hemorrhagic) thrombocythemia (9962/3)

Includes: Essential thrombocytosis, idiopathic hemorrhagic thrombocythemia

 

 

D47.4

Osteomyelofibrosis (9961/3)

Includes: Chronic idiopathic myelofibrosis Myelofibrosis (idiopathic) (with myeloid metaplasia)

  Myelosclerosis (megakaryocytic) with myeloid metaplasia) Secondary   myelofibrosis in myeloproliferative disease

D47.Z-

Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified (9960/3, 9970/1, 9971/3, 9931/3)

D47.9

Neoplasm of uncertain behavior of lymphoid, hematopoietic and related tissue, unspecified (9970/1, 9931/3)

D49.6, D49.7

Neoplasm of unspecified behavior of brain, endocrine glands and other CNS

R85.614

  Cytologic evidence of malignancy on smear of anus

R87.614

Cytologic evidence of malignancy on smear of cervix

R87.624

Cytologic evidence of malignancy on smear of vagina

 

 Note: Pilocytic/juvenile astrocytoma M-9421 moved from behavior /3(malignant) to /1 (borderline malignancy) in ICD-O-3. However, SEER registries will CONTINUE to report these cases and code behavior as /3 (malignant).

 

        

ICD-9-CM Code

Explanation of Code

140.0 - 172.9

Malignant neoplasms

173.00

Unspecified malignant neoplasm of skin of lip

173.09

Other specified malignant neoplasm of skin of lip

173.19

Other specified malignant neoplasm of skin of eyelid

173.29

Other specified malignant neoplasm of skin of ear

173.39

Other specified malignant neoplasm of skin of face

173.49

Other specified malignant neoplasm of skin of scalp

173.59

Other specified malignant neoplasm of skin of trunk

173.69

Other specified malignant neoplasm of skin of arm

173.79

Other specified malignant neoplasm of skin of leg

173.89

Other specified malignant neoplasm of skin of other

173.99

Other specified malignant neoplasm of skin NOS

174.0 - 209.36

Malignant neoplasms

209.70 - 209.79

Secondary neuroendocrine tumors

225.0 - 225.9

Benign neoplasm of brain and spinal cord neoplasm

227.3 - 227.4

Benign neoplasm of pituitary gland, craniopharyngeal duct (pouch) and pineal gland

227.9

Benign neoplasm; endocrine gland, site unspecified

228.02

Hemangioma; of intracranial structures

228.1

Lymphangioma, any site

230.0 - 234.9

Carcinoma in situ

236.0

Endometrial stroma, low grade

237.0 - 237.9

Neoplasm of uncertain behavior (borderline) of endocrine glands and nervous system

238.4

Polycythemia vera

238.6 - 238.79

Other lymphatic and hematopoietic diseases

239.6 - 239.89

Neoplasms of unspecified nature

273.2

Other paraproteinemias

273.3

Macroglobulinemia

288.3

Eosinophilia

288.4

Hemophagocytic syndromes

795.06

Pap smear of cervix with cytologic evidence of malignancy

795.16

Pap smear of vagina with cytologic evidence of malignancy

796.76

Pap smear of anus with cytologic evidence of malignancy

V10.0 - V10.91

Personal history of malignancy

V12.41

Personal history of benign neoplasm of the brain

 

This procedure is imperative to assure that no cases have been missed, including those originally diagnosed by clinical methods only.  A list of detailed and supplemental ICD-10-CM codes effective 10/01/2015 thru 09/30/2016 which may also be used for casefinding is available in APPENDIX M .  

 

Follow this link for a casefinding list of reportable ICD-10 codes effective 10/01/2015, which includes a comprehensive list plus a supplemental list. http://seer.cancer.gov/tools/casefinding/case2016-icd10cm.html

 

 

2.  Pathology reports:

 

All pathology reports on both inpatients and outpatients should be reviewed for case reportability. Since most cancer patients have a biopsy or operative resection performed, nearly all of the reportable cases can be identified through pathology reports alone. Histologic diagnoses are based upon microscopic examination of tissue taken from such procedures as biopsy, frozen section, surgery, or D & C. Expand path report screening to include benign CNS tumors, beginning with 1-1-04 diagnoses. Check for cases of anal intraepithelial neoplasia, grade III (AIN III), ductal intraepithelial neoplasia 3 (DIN 3), vaginal intraepithelial neoplasia, grade III (VAIN III), vulvar intraepithelial neoplasia, grade III (VIN III), Laryngeal intraepithelial neoplasia III (LIN III), Lobular neoplasia grade III (LN III)/lobular intraepithelial neoplasia grade III (LIN III),  Penile intraepithelial neoplasia, grade III (PeIN III), and Squamous intraepithelial neoplasia III (SIN III) excluding cervix.

 

NOTE: Path reports may be the best source for finding cases of VIN, VAIN, and AIN (8077/2) and DIN (8500/2).


3.  Cytology reports:

 

All cytology reports for both inpatients and outpatients should be reviewed for case reportability. Cytologic diagnoses are based upon microscopic examination of cells as contrasted with tissues. Included are smears from sputum, bronchial bushings, bronchial washings, tracheal washings, prostatic secretions, breast secretions, gastric fluid, spinal fluid, peritoneal fluid, pleural fluid, and urinary sediment. Cervical and vaginal smears are common examples.

 

4.  Autopsy reports.

 

5.  Radiation Therapy Department logs.

 

6.  Medical Oncology Department logs.

 

7.  Outpatient Department:

 

New patient registration rosters, clinic appointment books, surgery schedules, diagnostic imaging, and billing departments are additional casefinding sources.

 

8.  Alpha listing of previously included cases:

 

Casefinding cannot be considered complete until the CPDMS.net accession list and any previous registry accession lists have been checked to be sure that this is a new patient or a new primary.

 

Creating and Maintaining a Nonreportable List

In the course of routine casefinding activities, cases which are found to be nonreportable by your hospital should be added to a nonreportable list.  The list should consist of each patient’s name, DOB, SSN, medical record number, the type/site of cancer, and a brief explanation of why the case is not reportable to the hospital registry (i.e., "patient was seen for consult only, no dx or tx," or "patient originally diagnosed prior to reference date").  A well-maintained nonreportable list will save registrars time by preventing them from reviewing a chart multiple times to check on a particular primary that does not need to be abstracted.  The list can be invaluable during casefinding audits by allowing quick resolution of possible missed cases.  It is also helpful during the death clearance process.

 

Bear in mind that cases which are not reportable by your hospital, but which ARE reportable to KCR (see Case Reporting Requirements) should be sent to the central registry to be abstracted there.  These may include:

 

• A specimen from an outside doctor’s office which was sent to your hospital’s path lab

• Any case that was diagnosed and/or treated only in a nonhospital facility

• A Kentucky resident who was initially diagnosed or treated out of state