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guidelines for cancer data reporting

1. Topography Codes Description C70 0 Meninges C70 1 Cerebral Meninges C70 9 Spinal meninges Meninges NOS C71 0 Brain C71 1 Cerebrum C71 2 Frontal lobe C71 3 Temporal lobe C71 4 Parietal lobe C71 5 Occipital lobe C71 6 Ventricle NOS C71 7 Cerebellum NOS C71 8 Brain stem C71 9 Overlapping lesion of brain Brain NOS C72 0 Spinal Cord Cranial Nerves and Other Parts C72 1 of the Central Nervous System C72 2 Spinal cord C72 3 Cauda equina C72 4 Olfactory nerve C72 5 Optic nerve C72 8 Acoustic nerve C72 9 Cranial nerve NOS Overlapping lesion of brain and central nervous system Nervous system NOS C75 1 Other Endocrine Glands and Related C75 2 Structures C75 3 Pituitary gland Craniopharyngeal duct Pineal gland Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 13 B CASEFINDING Casefinding is the method used to identify new cancer cases inpatient or outpatient All facilities are responsible for complete casefinding for all patients seen at your facility regardless of type of service It is important that the following multiple sources in the hospital be searched to keep missed reportable cases to a minimum The procedure outlined below should be adapted to each individual facility o HIM Medical Record Disease Indices or Unified Billing System Report Inpatient and outpatient including inpatient hospice o Pathology surgical pathology bone marrow biopsy n
2. June 30 The June 30 Deadline is an annual milestone for cancer reporting in Florida Florida law requires that all cancer cases diagnosed treated for cancer having a cancer related health visit while undergoing cancer treatment or having any evidence of disease at the time of encounter must be abstracted and transmitted to FCDS within 6 months of the date of first encounter for cancer FCDS reinforces the 6 month reporting standard with a June 30 Deadline each year Compliance and Data Quality Reports are run following the annual June 30 Deadline Facilities not in compliance with the 6 month reporting rule will be notified by FCDS of the delinquency Each facility will be asked to develop a remedial plan to bring the facility back into compliance with state statutes with a plan to remain in compliance If no action is taken Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 22 or delinquency continues FCDS will notify the Florida Department of Health that the facility is non compliant and further action will be taken Any remediation or other action plan must be approved by the Florida Department of Health and FCDS FCDS will monitor the plan 8 Required Recommended Desktop References paper and or electronic current version REQUIRED DESKTOP REFERENCES REQUIRED REFERENCE ORDERING INFORMATION Current FCDS Data Acquisition Manual FCDS Florida Canc
3. D47 4 Osteomyelofibrosis 9961 D47 7 Other specified neoplasm of uncertain unknown behavior of lymlphoid hematopoietic 9965 9966 9967 9971 9975 9987 D47 9 Neoplasm of uncertain behavior of lymphoid hematopoietic and related tissue unspecified i 9960 9970 9931 D49 6 D49 7 Neoplasm of unspecified behavior of brain endocrine glands and other CNS E34 0 Carcinoid Syndrome J91 0 Malignant Pleural Effusion K22 711 Barrett s esophagus with high grade dysplasia R18 0 Malignant ascites Z51 0 Encounter for antineoplastic radiation therapy Z51 1 Encounter for antineoplastic chemotherapy and immunotherapy B20 AIDS Note Medical coders are instructed to add codes for AIDS associated malignancies Screen 042 for history of cancers that might not be coded elsewhere Z85 _ Personal history of malignant neoplasm oe ET 6 03 Personal history of in situ and benign neoplasm and neoplasm of uncertain behavior Z92 21 Z29 23 Z92 25 Z92 3 Personal history of antineoplastic chemotherapy estrogen therapy immunosuppression therapy or irradiation radiation Note Pilocytic juvenile astrocytoma M 9421 is reported with the behavior coded 3 9421 3 not 9421 1 Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING C ABSTRACTING 1 Personnel Requirements Abstractor Training and FCDS Abstractor Code Abstractor Training Trained personnel must perform abstracting
4. Insitu Cancer of Cervix or CIN Ill 10 W R Other 11 Reportable Case Abstraced BUT Not found in FCDS files Abst Requested 12 NRR No Cancer Mentioned in Medical Record 13 Skins we elected not to FB since most of them tum out N R 14 NIR Hematopoietic Diseases Dx Prior to 2001 15 NRR Case DX Prior to FCDS Reference Date Same Cancer Same Facility 16 W R Benign or Borderline Brain CNS Tumor Dx Prior to 2004 20 Unknown if Reportable No Record of this Patient at this Facility 21 Unknown if Reportable Lost Medical Record 30 Unknown if Reportable No Follow Back Ever Retumed by this Facility 40 WIR Special Case Other 50 Hospice Case Not A Hospital 51 Transitional Care Center Not A Hospital coroaruna8 3 FCDS Bureau of Vital Statistics Casefinding Audits Death Clearance Audit FCDS staff will perform annual matching of the FCDS Master File to the Florida Bureau of Vital Statistics death files FCDS will provide the reporting facility with a list of unmatched Vital Statistics cases deaths that show the place of death as the reporting facility Consolidated Vital Statistics and AHCA Follow Back Casefinding Audits The Integrated Vital Statistics and AHCA Follow Back will be available via FCDS IDEA following the June 30 Reporting Deadline The facility abstractor will need to research these cases to determine if the patient did expire at the facility and whether or not the case meets the cancer reporting requirements If
5. P O Box 24128 Baltimore MD 21227 301 330 7968 To order by phone contact 1 800 4 CANCER and select the option to order publications You may use our online Publications Locator at http www cancer gov publications The SEER Program Coding and Staging Manual can be downloaded and they are available in both PDF and ZIP formats http seer cancer gov registrars http www seer cancer gov registrars See order for SEER publications http seer cancer gov publications SEER Program Instructional Manuals on CD ROM Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 24 Historical Staging and Coding Manuals on CD ROM SEER Program Code Manual current edition Order SEER Publications Online order form SEER publications available in hardcopy include reports and monographs coding manuals self instructional manuals for tumor registrars and ICD conversion materials National Cancer Institute Publications Ordering Service P O Box 24128 Baltimore MD 21227 301 330 7968 To order by phone contact 1 800 4 CANCER and select the option to order publications You may use our online Publications Locator at http www cancer gov publications http seer cancer gov tools codingmanuals index html CDC Data Collection of Primary Central Nervous System Tumors National Program of Cancer Registries Training Materials 2004 Cancer for Disease Control and Prevention CDC National Progr
6. The data on the CDs are updated when necessary with the most recent year being added as it becomes available FCDS will fill data requests for data CDs within 20 business days once the application has been approved and payment has been received by FCDS 2 Statistical Tabular Data All non CD requests for Data Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 37 All requests for non confidential statistical tabular data must be received in writing please use the form titled Data Request Form for statistical and tabular data found under the Data Requests link on the FCDS web site http fcds med miami edu This type of data request can be approved directly by FCDS The basic rule of thumb is that as long as the tabulation cannot either directly or indirectly identify any patient the data may be released In an effort to protect the indirect identification of the patient the rule of ten is applied this rule suppresses any cell containing fewer than 10 cases Tabulated data may be released at or above the county code level with a count of 10 or greater for counts less than 10 or data below the county level approval will be required from the Department of Health Because each request is unique FCDS staff will discuss the project with the requestor to verify the type of data required and determine if the system is capable of producing the required data and to determine approximately how long it will take to fill th
7. 49 999 3 000 fee plus 03 cents per record 50 000 99 999 3 500 fee plus 02 cents per record 100 000 249 999 4 000 fee plus 015 cents per record 250 000 5 000 fee plus 011 cents per record e Geocoded amp Patient Contact lists Sliding scale lt 10 000 1 500 10 000 24 999 2 000 25 000 49 999 2 500 50 000 99 999 3 000 100 000 249 999 3 500 250 000 4 000 Subsequent listing without changes to format layout or variables will be charged 50 percent of the sliding scale fee for the number of records extracted For example subsequent request for another 30 000 patient listing would be 2500 50 1 250 Overnight mailing actual cost Data linkage fees are charged for those projects involving the matching of an outside data source to the Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 39 Florida Cancer Data System database Please contact FCDS directly to discuss fields and the associated record layout A copy of the required record layout is available under the Data Request link on the FCDS web site http fcds med miami edu Data coordination fees apply to all data linkage projects they involve manually reviewing possible matches and correcting for any deviations in field length or variable formats Please contact FCDS prior to submitting a written request to discuss the analysis data extraction and to obtain an estimate of any fees Additional information such as publ
8. Facility Timeliness Report FCDS Data Quality Quality Control Program Components il On Site and or Remote Access Casefinding Audits The FCDS Quality Control staff will periodically perform review of casefinding procedures by auditing the casefinding sources within each facility This may be done in person at the facility or may be completed remotely utilizing a variety of facility generated data streams matched to the FCDS files Names identified will be compared to the FCDS Master File by the auditor The registrar at the facility will be asked to review their Not Reportable List and identify the reason for any case s found by the auditor that were not abstracted Medical records for cases not found in the FCDS Master File or on the Not Reportable List will have to be reviewed by the facility abstractor If any case is found to meet the cancer reporting requirements outlined in Section I the case must be abstracted and reported to FCDS For any case found that does not meet the cancer reporting requirements outlined in Section I an explanation must be submitted to FCDS detailing the reason it will not be reported FCDS Agency for Health Care Administration AHCA Casefinding Audits FCDS staff will perform annual matching of the FCDS Master File to the Florida Agency for Health Care Administration AHCA files for both inpatient and outpatient ambulatory patient encounters FCDS will provide the reporting facility with an
9. Lost Medical Record Unknown if Reportable No Follow Back Ever Returned by this Facility NIR Special Case Other Hospice Case Not A Hospital 51 Transitional Care Center Not A Hospital O Saro SooNnonaun R to o N 28s FREE STANDING RADIATION THERAPY CENTERS Those facilities that do not voluntarily report full cancer abstracts to FCDS will have to upload minimal data on all cancer patient encounters for casefinding using the FCDS IDEA FCDS will match the cancer records identified by each facility against the FCDS Master file Each record that does not match with a case in the FCDS Master file will be identified for reporting Please see APPENDIX I for detailed reporting guidelines PRIVATE PHYSICIAN OFFICES Practitioners licensed under Chapters 458 459 464 F S are required to report to the Florida Cancer Data System as required by Section 385 202 F S within six 6 months of each diagnosis and within six 6 months of the date of each treatment Each physician office shall submit each cancer case report electronically FCDS currently requires physician office claims reporting from medical oncology hematology urology and other physician practices Dermatology practices report under the Dermatology Reporting Module an abbreviated reporting mechanism designed to report skin cancers CLINICAL LABORATORY CANCER IDENTIFICATION PROGRAM Every anatomic pathology laboratory that reads biopsy and surgical resection
10. Specific fields a Historical information must be completed starting with the eight fields in HISTORY 1 Every additional historical case would use the next sequential group of eight fields i e HISTORY2 through HISTORY5 No gaps in the groups can exist Examples One Historical Case MUST use Historical 1 group of nine fields Two Historical Cases MUST use Historical 1 and Historical 2 groups of nine fields In the example of Two Historical cases if Historical 1 and Historical 3 groups of nine fields are populated than abstract will not be accepted due to a gap in Historical 2 group When a particular group is selected Historical 1 all nine fields must be filled Historical date must be completed in accordance with the current standards If any of these fields are left blank then the abstract and possibly the entire batch will be rejected Examples Historical 1 Sequence Number Historical 1 Dx Date Historical 1 Primary Site Historical 1 Histology Historical 1 Behavior Historical 1 Laterality Historical 1 Dx State Abbreviation Historical 1 Dx County FIPS Historical 1 CS SSF25 Discriminator Once these historical groupings pass structure check edits a full abstract will be generated from the data provided The derived Historical abstracts will be subject to our full set of edit checks If any failures exist the abstract and batch will be rejected 7 Annual Reporting Deadline
11. again and review whether or not it should have been reported to FCDS An explanation must then be submitted to FCDS detailing any reason any case will not be reported to FCDS or the case must be abstracted and reported to FCDS FCDS Disposition Codes may be included in the file as reference for reason the case is not reportable Description Reportable Missed Case Case to be Abstracted amp Reported by Facility NIR Tumor was Not Malignant Behavior 0 or 1 N R NonReportable Skin Cancer Site C44 and Morph 8000 to 8110 NIR No Evidence of Cancer at This Time NED N R Consultation Only NIR Cancer Not Proven Equivocal Case Previously Reported to FCDS by this Facility NIR Outpatient Record with No Active Cancer Documented in Record NIR Insitu Cancer of Cervix or CIN Ill WR Other 11 Reportable Case Abstraced BUT Not found in FCDS files Abst Requested 12 NIR No Cancer Mentioned in Medical Record 13 Skins we elected not to FB since most of them tum out N R 14 NIR Hematopoietic Diseases Dx Prior to 2001 15 NIR Case DX Prior to FCDS Reference Date Same Cancer Same Facility 16 NIR Benign or Borderline Brain CNS Tumor Dx Prior to 2004 20 Unknown if Reportable No Record of this Patient at this Faciity 21 Unknown if Reportable Lost Medical Record 30 Unknown if Reportable No Follow Back Ever Returned by this Facility 40 WIR Special Case Other 50 Hospice Case Not A Hospital 51 Transitional Care Center Not A Hos
12. first seen at the reporting facility prior to January 1 1981 July 1 1997 for free standing centers and returning after that date for the same primary malignant neoplasm Ainsi patients who receive transient care to avoid interrupting a course of therapy started elsewhere 3 Reportable Neoplasms Determination of whether or not a given primary neoplasm is reportable is made by reference to the morphology and behavior codes of the International Classification of Diseases for Oncology including any approved updates or errata published by WHO and approved by NAACCR for ICD O 3 Three newly reportable conditions were introduced with the 20 0 Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual Please refer to the most current version of the Hematopoietic Database and Manual for complete reporting instructions a In Situ and Invasive Cancers FCDS includes primary malignancies which are in situ and or invasive Therefore any cancer with an ICD O behavior code of 2 in situ or 3 invasive malignant is reportable to FCDS except carcinoma in situ of the cervix CIN III or PIN IID Cancers with benign or borderline behavior are discussed elsewhere in this section If a tumor with an ICD O behavior code of 0 or 1 is determined to be in situ or invasive by the manner in which it is behaving in malignant fashion or by a pathologist the case is reportable i Vaginal Intraepithelial Neoplasia VAIN IID and Vulvar Intraep
13. forth in Section II of this document Questions regarding the interpretation of individual data items should be referred to the FCDS office Note The ACoS CoC changed CoC Cancer Program Standard 5 2 abstracting timeliness on 1 1 2014 This is a change for CoC Cancer Program Accreditation and does not change the Florida 6 month reporting requirement or the FCDS June 30 Deadline Florida Statute requires that cases be completely abstracted all information must be included regarding the diagnosis staging first course of treatment cancer progression or recurrence within 6 months of first patient encounter for cancer at your facility Do not send FCDS a partial abstract as part of ACoS CoC Rapid Quality Reporting System RQRS Note The CoC FORDS Manual instructs registrars from CoC Programs that the data item Date Case Completed should not be filled in until the case has been completed and all data required have been abstracted coded The case is pending completion until all first course treatment has been investigated and documented in the original abstract sent to FCDS and the final abstract that is sent to the NCDB not the initial RQRS report All abstracts are required to pass the FCDS EDITS metafile 3 Not Reportable List A list of cases reviewed but not reported to FCDS not reportable list should be maintained by each reporting facility either in electronic or other format This can be as part of your abstracting
14. least one week to take the examination again Registrars should not abstract cancer cases between failed exams gt Abstractors who successfully pass the examination will be assigned a Florida Cancer Data System Abstractor Code Codes are renewed annually gt NEVER share your abstractor code or your code may be suspended or revoked Before taking the exam please read through and become familiar with the FCDS DAM to ensure you understand all of the Florida abstracting and data collection requirements The current version FCDS DAM can be found on our website http fcds med miami edu There are a few Florida specific requirements critical to complete reporting in Florida that many out of state registrars miss reporting of non analytic cases and all sequences for historical cancers FCDS monitors use of individual codes and is alert to the practice of sharing abstractor codes for new staff temporary staff and even permanent staff Please be secure with your abstractor code abstracted data personal information and all confidential materials A breach of confidentiality and or of protected personal health information or PHI also known as a HIPAA Violation may result in substantial civil monetary penalties up to 1 5 million in a single calendar year and or criminal penalties of up to 10 years in federal prison Revised 2014 10 11 SECTION I GUIDELINES FOR CANCER DATA REPORTING 34 Personal Health Information PHI i
15. software Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 19 maintained in your suspense file or in a separate document with easy access A sample form is included at the end of this Section Any patient encounter that appears on a facility casefinding list that does not meet the reporting requirements outlined in Section I should be recorded on the Not Reportable List with an explanation as to why the case will not be reported FCDS suggests you also include the FCDS Disposition Code associated with the reason not reported to facilitate your annual AHCA Follow Back activities The list should include the patient s name social security number medical record number date of birth ICD 9 CM or ICD 10 CM code admission date and disposition code or reason they were not reported The list may be kept in a paper notebook spreadsheet vendor software suspense file or in any other easily accessible format You may use the FCDS form or you may create your own Casefinding audits are performed periodically at every reporting facility as well as through annual case matching with the Florida Agency for Health Care Administration AHCA data files to assure completeness of reporting The not reportable list will expedite resolution of cases that show up as missed cases during these casefinding audits Failure to keep the list will result in FCDS requesting that the reporting facility pull each missed case record
16. up to five 5 historical cases The fields required for each of the five cases include Sequence Number Diagnosis Date Primary Site ICD O 3 Histology ICD O 3 Behavior ICD O 3 Laterality State of Residence at Diagnosis State Abbreviation County of Residence at Diagnosis FIPS County Code CS SSF 25 Discriminator SOO GY i b These fields will be edited at time of transmission and will include Sequence Number and Diagnosis Date edit checks as well as State and County edit checks c These fields should ONLY be used when abstracting a historical case with insufficient information A complete full abstract MUST be reported to FCDS for those cases with sufficient information in the patient s medical record or if the patient has evidence of the Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 21 historical cancer at the time of patient encounter persistent disease progression of disease or disease recurrence patient with evidence of this cancer at the time of patient encounter REMEMBER the minimal dataset only applies to Class of Case 33 Historical Cases with insufficient information All other Non Analytical cases including Class of Case 33 historical cases with sufficient information REQUIRE a full abstract be reported to FCDS Quality Control for these cases will be increased and documentation supporting the minimal dataset may need to be provided 6 Reporting Historical Cases in the State
17. verification of patient information death certificate notification AHCA casefinding audits etc Any discrepancies or omissions that are discovered after an abstract has been transmitted and processed will be posted to FCDS IDEA for review and or correction A SAMPLE FCDS Discrepancy Journal is provided at the end of this Section As a courtesy FCDS will make every attempt to inform contractors of outgoing edits quality control inquiries verification of patient information death certificate notification AHCA casefinding audits etc However the contractor and the reporting facility are ultimately responsible for assuring these reports and inquiries reach the contractor through appropriate channels CONFIDENTIALITY Patient information personal health information medical records and healthcare facility data are all confidential and continue to be a concern with regard to cancer and other disease reporting Please do not fax or email patient information to FCDS Also please take care Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 25 when discussing cases over the phone with FCDS staff DO NOT E MAIL FAX OR MAIL PATIENT INFORMATION PHD TO FCDS UNDER ANY CIRCUMSTANCES unless you are provided specific instructions for using our Secure Fax Service CONFIDENTIAL INFORMATION includes any HIPAA defined Protected Health Information PHI information in the healthcare includes Patient name address including street
18. 1 Ths Vital Statistics Record Matches an AHCA Record For FCDS Use Only 50 Hospice Case Not A Hospital 51 Transitional Care Canter Not A Hospital 52 NotA Hospital NOS 53 Closed Facility No Records Avaliable 54 Nursing Home Death or Residence Death Not A Hospital Death WON KAOhk Wh Oo 4 FCDS EDITS Metafile includes Field Item Inter Item and Intra Item Data Edits Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 31 FCDS uses a standard EDITS Metafile that has been modified to meet Florida requirements The FCDS EDITS Metafile can be found on the FCDS website as well as a master listing of changes by date FCDS EDITS include data edits to validate codes crosscheck related data items and records and check for blank fields The Florida specific data edits were created for all Florida only fields as well as for common abstracting errors identified through re abstracting audits Edits are reviewed as needed monthly New edits are added as needed QC Visual Review Sampling of Every 25 Record FCDS Quality Control staff visually reviews every 25 record submitted by each reporting facility The Quality Control Visual Review is designed to facilitate visual editing of abstracted data It allows a trained eye to detect inconsistent coding that electronic edit checks cannot identify it is a tool to identify deficiencies in abstractors understanding of abstracting concepts data definitions and coding selections
19. 9421 3 for primary sites as defined in the Table Primary Site Codes for Non Malignant Primary Intracranial and Central Nervous System Tumors Exceptions not 1 Skin cancers C44 _ with histologies 8000 8110 2 CIS of the cervix and CIN III 3 PIN MI after 1 1 2001 1 Skin cancers C44 _ with histology 8000 8110 after 1 1 2003 prior to that date AJCC stage groups 2 4 in this group were reportable 2 CIS of the cervix and CIN 1 Skin cancers C44 _ with histologies 8000 8005 8010 8046 8050 8084 8090 8110 2 CIS of the cervix and CIN IM 3 PIN IM after 1 1 2001 reportable III after 1 1 96 3 PIN IM after 1 1 96 4 VIN II after 1 1 96 5 VAIN III after 1 1 96 6 AIN after 1 1 96 If a patient has at least one Not included unless patient Not included unless patient has evidence primary reportable neoplasm has evidence of this neoplasm of this neoplasm active disease which is active or under active disease Historical treatment all other primary reportable neoplasms the Neoplasm patient has ever had active or inactive regardless of the date of diagnosis must be reported to FCDS Multiple Primary 2007 Multiple Primary and 2007 Multiple Primary and 2007 Multiple Primary and Histology Rules Histology Coding Rules Histology Coding Rules Coding Rules shpi 2014Hematopoietic and 2014 Hematopoietic and 2014 Hematopoietic and Lymphoid Hematopoietic Lymphoid Neoplasm Case L
20. E EXAM Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 18 Y Individuals hoping to acquire a NEW FCDS Abstractor Code will need to take the New FCDS Abstractor Code Exam v Ifan individual s FCDS Abstractor Code has been expired for greater than 2 years the individual must re apply and take and pass the New FCDS Abstractor Code Exam WHO NEEDS TO TAKE THE FCDS ABSTRACTOR CODE RENEWAL EXAM v Individuals with an ACTIVE not yet expired FCDS Abstractor Code will be required to take and pass the FCDS Abstractor Code Renewal Exam once their code has expired Y Individuals with an EXPIRED FCDS Abstractor Code will be required to take the FCDS Abstractor Code Renewal Exam each year in order to keep their FCDS Abstractor Code current and to renew their individual FCDS Abstractor Code annually 2 Case Abstracting Requirements Timeliness Individual cases must be abstracted no later than six months after the date of first contact with the reporting facility The only exceptions to this reporting timeline are the free standing ambulatory surgical centers who are reporting under the Ambulatory Centers Cancer Reporting Program Cases may be abstracted earlier than six months after the date of first contact but only if the required information regarding first course of therapy is available and complete All cases meeting the reporting requirements outlined in Section I A must be abstracted following the guidelines set
21. FCDS provides basic incidence abstracting training via web based modules The 20 web based modules constitute one course in the FCDS Learning Management System The modules include 1000 slides with voice overs exercises and quizzes to monitor progress Modules are available at http moodle med miami edu server moodle In addition FCDS performs on site regional and statewide workshops on an ad hoc basis Other training is available through SEER Educate the Commission on Cancer National Cancer Registrars Association and NAACCR FCDS Abstractor Code Every registrar abstractor planning to work in the State of Florida is required to obtain an individual FCDS Abstractor Code This code is assigned by FCDS to persons who successfully pass the FCDS Abstractor Code On Line Examination regardless of certification by NCRA as a CTR experience in the registry industry or other factors As of January 1 2013 any individual planning to acquire a New FCDS Abstractor Code or planning to Renew an Existing FCDS Abstractor Code must take and pass the FCDS Abstractor Code Exam The FCDS Abstractor Code Requirement has been FCDS Policy for many years and applies to every cancer registrar working in the state of Florida CTR or non CTR Florida resident or out of state contractor regardless of number of years experience FCDS will not accept cases from individuals without an Active Current FCDS Abstractor Code While the FCDS Abstractor Code Requiremen
22. S is not reportable to FCDS This includes Cervical Intraepithelial Neoplasia CIN Grade I III and in situ adeno carcinoma c Prostate Intraepithelial Neoplasia PIN Grade I III is not reportable to FCDS Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 5 d New terminology may be used by your local pathologist to describe malignant or in situ neoplasms i e well differentiated neuroendocrine neoplasm When this occurs the neoplasm is reportable to FCDS 5 Reporting Multiple Primary Tumors Single versus Multiple Primaries Operational rules are needed to ensure consistency in reporting multiple primary neoplasms Basic factors include the anatomic site of origin of the neoplasm the date of diagnosis the histologic type of each neoplasm the behavior of the neoplasm and laterality Please consult the attending physician if questions arise regarding the number of primary tumors In general if there is a difference in the primary site where the neoplasm originates it is fairly easy to determine whether it is a single or multiple primaries regardless of dates of detection or differences in histology Likewise if there is a clear cut difference in histology other data such as the primary site and the date of detection are not essential to make this determination Standardized rules have been developed and published to assist the registrar in making single versus multiple primary decisions 2007 Multiple Prima
23. SECTION I GUIDELINES FOR CANCER DATA REPORTING The Florida Cancer Data System FCDS is charged with maintaining a high quality database of useable timely complete and accurate cancer data for every reportable case of cancer diagnosed or treated in the state of Florida The FCDS Data Acquisition Manual FCDS DAM includes guidelines and instructions for case identification case eligibility which cases must be reported to FCDS abstracting and coding and multiple appendices that are referenced throughout the manual The manual only addresses data items that are required by FCDS and the Florida Department of Health to support Florida s statewide population based cancer registry These guidelines have been established as a means to achieve and maintain this objective All reporting facilities regardless of affiliation MUST adhere to the following guidelines for cancer data reporting The instructions and codes in this manual take precedence over all previous instructions manuals It is the responsibility of both the reporting facility and the facility abstractor or contractor to be familiar with and understand the content of the most current version of the FCDS Data Acquisition Manual and to update it upon receipt of any changes from FCDS This responsibility exists without regard to whether or not case abstracting and reporting is being performed by an employee of the reporting facility or through some contractual arrangement with an independen
24. am of Cancer Registries 4770 Buford Hwy NE Mail Stop K 53 Atlanta GA 30042 3717 Phone 1 888 842 6355 Fax 770 488 4760 http www cdc gov cancer npcr training btr DATA TRANSMISSION Batched Records or Single Case Entry plus Edits Corrections QC ALL CASES MUST BE TRANSMITTED TO FCDS ELECTRONICALLY using FCDS secure information and data sharing portal the FCDS IDEA and in accordance with all FCDS Data Submission Policies and Procedures See Appendix Q for FAQs on the FCDS IDEA RELEASE OF INFORMATION FCDS will not release any patient information directly to any contractor due to liability and confidentiality issues regarding contractual agreements not involving FCDS Furthermore new guidelines set forth under HIPAA Health Insurance Portability and Accountability Act have introduced additional restrictions regarding releasing and re releasing patient information under many circumstances FCDS understands that this policy may present some challenges to some contractors Any contract between a healthcare facility and a private contractor where FCDS is not a party to the contract cannot include allowances for FCDS to release patient information to anyone other than the reporting facility Contractors must make arrangements with their clients facilities to forward any FCDS correspondence that includes patient information to them contractor This includes but is not limited to edit discrepancies quality control inquiries
25. ansitional Care Center Not A Hospital 0O BSARSHSGOeVIAHONA E 28 es Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 14 2 Pathology Reports All pathology reports including surgical path reports bone marrow aspirations needle biopsies and fine needle aspiration biopsies diagnostic hematology cytology and autopsy reports for inpatients outpatients and ambulatory care patients must be reviewed to determine whether or not a case is reportable Pathology Reports should also be submitted electronically to FCDS under the FCDS E Pathology Reporting Program Since most cancer patients have a biopsy or operative resection performed nearly all of the reportable cases can be identified by pathology reports alone Check with your pathology department to see if the department information system can be used to facilitate the review of these reports Pathology reports must also be reviewed within each reporting facility at least annually to insure that no cases have been missed by the reporting facility 3 Radiation Therapy Department New patient registration rosters and radiation therapy summaries are excellent casefinding sources for patients treated with radiation Unified Billing System Reports also can be used to identify these cases 4 Qutpatient Departments New patient registration rosters for single day surgery departments oncology related service areas specialty clinics chemotherapy clinics infus
26. any anti neoplastic agent s through the port a cath for the case to meet this exclusion criterion If any anti neoplastic agent is administered at the reporting facility either as an outpatient or inpatient the case must be reported Note Facilities may opt to abstract and report port a cath placement cases at their discretion 1 Reportable Patients All patients first seen at the reporting facility on or after January 1 1981 July 1 1997 for free standing ambulatory surgery centers and freestanding radiation therapy centers whether as an inpatient outpatient or in an ambulatory care setting who meet one or more of the following criteria must be reported A ET all patients with an active malignant neoplasm in situ or invasive whether being treated or not b oe all patients with an active benign or borderline brain or central nervous system CNS tumor diagnosed on or after 01 01 2004 whether being treated or not C anene all patients undergoing prophylactic or adjuvant therapy for malignancy A ia all patients diagnosed at autopsy eja all historical cases that meet FCDS reportability guidelines 2 Not Reportable Patients A S patients seen only in consultation to provide a second opinion to confirm a diagnosis or a treatment plan no additional testing can be performed at your facility or the case is reportable Biste patients in remission NED and not receiving prophylactic or adjuvant therapy AE patients
27. any case is found to meet the reporting requirements the case must be abstracted and reported to FCDS For each case that will not be reported to FCDS or did not expire at the reporting facility FCDS requires a brief statement be submitted that sufficiently explains why the case will not be reported Please reference the Death Clearance Disposition Codes Listing below for reason not reported to FCDS Description Missed Case Case Abstracted amp Reported by Faciity NR Tumor was Not Malignant Behavior 0 or 1 NR NonReportable Skin Cancer Site C44 and Morph 8000 to 8110 NR No Evidence of Cancer at This Time NED NR Consultation Only NR Cancer Not Proven Equivocal Case Previously Reported to FCDS by tis Facility NR Outpatient Record with No Active Cancer Documented in Record NR Instu Cancer of Cervix or CIN Ill VIN Ill VAIN Ill PIN Ill 10 NR Other 11 Case Abstracted by Facility but Not found in FCDS Masterfie 12 NR No Menton of Cancer in Medical Record 13 This low back code no longer valid 14 NIR Non Reportable Myeloproilferative Disease Ox Prior to 2001 15 NR Case DX Prior to FCDS Reference Date Same Cancer Same 16 NR Benign or Borderline BralvCNS Tumor Dx Prior to 2004 20 _Uninown if Reportable No Record of this Patent at this Faciity 21 Unknown if Reportable Lost Medical Record 30 Unimown if Reportable No Follow Back Info ever Returned by Facility 40 NIR Special Case Other 4
28. ble as of 01 01 2004 This includes benign and borderline tumors of intracranial glands pituitary gland pineal gland and tumors of the craniopharyngeal duct meningioma and tumors of cranial nerves CDC published a reference manual in 2004 entitled Data Collection of Primary Central Nervous System Tumors The manual is available free of charge in PDF format on the CDC NPCR Website at http www cdc gov npcr pdf btr braintumorguide pdf This document and ICD O 3 are the primary references when determining case reportability for primary brain and CNS tumors If the diagnoses date of a benign or borderline brain and CNS tumor is unknown and the admission date is 01 01 2004 or later the case is reportable Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING Benign and borderline brain and CNS tumors diagnosed prior to 01 01 2004 are reportable as historical cases when accompanied by another reportable primary on or after 01 01 2004 e Pilocytic Juvenile astrocytoma is reportable code the histology and behavior code 9421 3 f Table of Anatomic Primary Sites for Reportable Benign and Borderline Tumors of Intra cranial and other central nervous system tumors Anatomic Intracranial and CNS Sites for Reportable Benign Borderline Tumors General Term Anatomic Site ICD O 3 Code Meninges Cerebral meninges C700 Spinal meninges C701 M
29. cannot be ruled out cannot be ruled out cannot be ruled out equivocal equivocal equivocal Terminology NOT utes Possible roseibls Considered as potentially malignant potentially malignant potentially malignant Diagnostic of questionable questionable questionable rule out rule out rule out Cancer suggests suggests suggests 10 Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 11 worrisome worrisome worrisome Juvenile astrocytoma is reported as 9421 3 Do not substitute synonyms such as supposed for presumed or equal for comparable Do not substitute likely for most likely Use only the exact words on the list Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING Table 3 Primary Site Codes for Non Malignant Primary Intracranial and Central Nervous System Tumors non malignant primary intracranial and central nervous system tumors with a behavior code of 0 or 1 benign borderline are reportable regardless of histologic type for these topography codes The CDC Brain Tumor Guide entitled Data Collection of Primary Central Nervous System Tumors is available for reference http www cdc gov cancer npcr pdf btr braintumorguide pdf Reference Standards for Cancer Registries Volume I Data Standards and Data Dictionary Sixteenth Edition Version 14 Chapter III Standards for Tumor Inclusion and Reportability
30. city county zip code and equivalent geo codes Name of relatives Name of employers All elements of date pertaining to patient ex admission discharge and birthdate Telephone numbers Fax numbers Electronic email addresses Social Security number medical record number Health plan beneficiary number Account number Certificate and license number Any vehicle or other device serial number Web Universal Resource Locator URL Internet Protocol IP address number Finger or voice prints Photographic images O 070 OCO OF T OOO OMO OO OIO 1 Quarterly Reporting FCDS REQUIRES THAT FACILITIES TRANSMIT DATA AT LEAST QUARTERLY MONTHLY DATA SUBMISSION IS RECOMMENDED FOR LARGE FACILITIES facilities reporting over 500 cases year 2 Electronic Submissions Record Layout All data must be submitted in the current NAACCR Version transfer record layout The FCDS field positions and field lengths are standardized using the NAACCR transfer record layout data definitions and data exchange guidelines All fields identified as Core C must be filled using valid codes Any field identified as Optional O may be submitted to FCDS as optional 3 Receipt on Upload An Upload Receipt is generated after the upload is successfully transmitted 4 Data Acceptance Policy FCDS EDITS Batch submissions will be edited immediately upon upload using the standard FCDS EDITS metafile This metafile is publis
31. cord that does not match with a case in the FCDS Master file is identified on the AHCA Unmatched Cancer Records Request listing for reporting 3 Unmatched Ambulatory Surgery Center Cases are posted to the FCDS IDEA Cases must be reviewed for reportability and abstracted using FCDS IDEA Single Entry If the case is not reportable the appropriate AHCA Disposition Code must be entered in FCDS IDEA to explain why the facility will not report the case Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 27 Description Reportable Missed Case Case to be Abstracted amp Reported by Facility N R Tumor was Not Malignant Behavior 0 or 1 N R NonReportable Skin Cancer Site C44 and Morph 8000 to 8110 NIR No Evidence of Cancer at This Time NED NIR Consultation Only NIR Cancer Not Proven Equivocal Case Previously Reported to FCDS by this Facility NIR Outpatient Record with No Active Cancer Documented in Record NIR Insitu Cancer of Cervix or CIN III WR Other Reportable Case Abstraced BUT Not found in FCDS files Abst Requested N R No Cancer Mentioned in Medical Record Skins we elected not to FB since most of them tum out N R NIR Hematopoietic Diseases Dx Prior to 2001 NIR Case DX Prior to FCDS Reference Date Same Cancer Same Facility NIR Benign or Borderline Brain CNS Tumor Dx Prior to 2004 Unknown if Reportable No Record of this Patient at this Facility Unknown if Reportable
32. d fees 5 Cancer Cluster Data Requests for information regarding potential cancer clusters should be directed to the County Health Department If necessary staff at the County Health Department will contact the appropriate division at the central office of the Florida Department of Health for assistance 6 Fees and Billing Procedure Each reporting facility has an annual 200 credit which can be applied to data requests only with regard to data submitted from their institution Requests should be submitted in writing on company letterhead If the data is to be sent to a third party this request should be specified in the letter The billing procedure for the Confidential CDs is as follow once payment and supporting documentation are received the CD is mailed out For all other data requests an invoice will be mailed via email or postal service along with the results of the data request or linkage Most requests generate a fee The FCDS does not receive additional funding to perform special ad hoc data analysis therefore actual costs are passed on to the applicant The fees are as follows Public use CD No Charge Minimum charge 150 00 Statistical analysis programming data coordination 150 00 per hour e Limited Confidential CD without geocodes 500 00 e Full Confidential CD with geocodes 1 000 e Data Linkage Sliding scale lt 10 000 3 000 10 000 24 999 2 500 fee plus 05 cents per record 25 000
33. e most current version as these rules and codes replace all previous versions DO NOT USE ICD O 3 to code any histology 9590 9992 Use the Heme Manual and Database 6 Clarification of Reporting Requirements a Malignant Neoplasms Benign tumors A patient is considered to have a benign borderline or malignant neoplasm when so indicated by a recognized medical practitioner In determining a diagnosis of cancer a positive pathology report takes precedence over all other reports or statements Many benign and borderline neoplasms of the brain and central nervous system are diagnosed based upon diagnostic imaging only CT PET MRI etc Other cancers may be diagnosed by alternate means such as direct visualization without biopsy or a diagnosis may be based upon clinical evidence alone The data item Diagnostic Confirmation is used to identify the method of diagnosis for each case The codes are to be used in a hierarchical order in most cases In the absence of a positive pathology report all information in the record must be assessed to determine whether or not the case is reportable and to identify the method used to establish confirm the diagnosis b Clinically Diagnosed Cases Are Reportable Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 6 In the absence of a histologic or cytologic confirmation of a reportable cancer accession a case based on the clinical diagnosis when a recognized medical practit
34. e request Based on this information an estimate of the cost is provided Then the applicant will need to submit the request in writing FCDS staff may contact the requestor as needed to discuss and clarify additional details of the request FCDS will fill data requests for statistical tabular data within 20 business days once the request has been finalized and the cost has been approved 3 Confidential Data All requests for confidential data any data that can directly identify a patient must be sent to the Florida Department of Health DOH for approval using both the DOH Bureau of Epidemiology and the DOH Institutional Review Board IRB Please refer to the Procedure Guide for Studies that Utilize the Florida Cancer Data System Data for Patient Identification and Contact for application materials and submission requirements The Procedure Guide can be found at http fcds med miami edu inc datarequest shtml Further information on the DOH IRB application process and timeline can be found at http www doh state fl us execstaff irb index html For questions please contact Florida Department of Health Bureau of Epidemiology Cancer Registry Re Confidential Data Request 4052 Bald Cypress Way Bin A 12 Tallahassee FL 32399 1720 Telephone 850 245 4401 Fax 850 922 9299 Once approval has been received from both the DOH Bureau of Epidemiology and DOH IRB FCDS staff will then begin to work directly with the researcher FCDS
35. eedle biopsy cytology autopsy etc o Radiation Therapy Department Radiation oncology logs o Outpatient Departments including cancer specialty clinics chemotherapy clinics infusion centers day surgery emergency room medical oncology logs etc o Diagnostic Imaging Radiology Department MRI CT scan PET scan x ray mammogram etc 1 HIM Medical Record Disease Index Unified Billing System Report Every patient record with a reportable ICD 9 CM code see Current Casefinding List must be reviewed to determine whether or not the case meets FCDS criteria for case reporting It is essential that all patient service areas be included in these reports ICD 10 CM and ICD 10 PCS will be adopted as a new standard on 10 1 2015 ICD 10 CM Casefinding List is included in this and previous FCDS DAM documents Please ensure your facility IT staff has been given a copy of the ICD 10 CM list to avoid interruption in casefinding for the last quarter of calendar year 2015 Upon review if a patient is found not to have a malignancy as coded by the HIM Medical Record or Billing Department or does not meet FCDS criteria for case reporting the name should be added to the facility s Not Reportable List The list may be substituted with the facility suspense file based on available vendor tools The Not Reportable List is useful when FCDS is conducts casefinding audits based on AHCA data Some facilities will save a Not Reportab
36. electronic list of Unmatched AHCA Cases cases that appear in the AHCA files but have no matching record in the FCDS Master File available on the FCDS website Consolidated AHCA and Vital Statistics Follow Back Casefinding Audits The Consolidated AHCA and Vital Statistics Follow Back will be available via FCDS IDEA following the June 30 Reporting Deadline The facility abstractor then must compare the list of Unmatched AHCA Cases to the facility Not Reportable List Cases that appear on the Unmatched AHCA Cases listing but do not appear on the Not Reportable List will need to be reviewed by the facility abstractor Upon review if any case is found to meet the cancer reporting requirements outlined in Section I the case must be abstracted and reported to FCDS These cases are a priority reporting item and must be abstracted as soon as possible Please reference the AHCA Disposition Codes List for reason not reported to FCDS Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 30 Description Reportable Missed Case Case to be Abstracted amp Reported by Facility N R Tumor was Not Malignant Behavior 0 or 1 NIR NonReportable Skin Cancer Site C44 and Morph 8000 to 8110 NIR No Evidence of Cancer at This Time NED NIR Consultation Only NIR Cancer Not Proven Equivocal Case Previously Reported to FCDS by this Facility NIR Outpatient Record with No Active Cancer Documented in Record NIR
37. eninges NOS C709 Brain Cerebrum C710 Frontal lobe C711 Temporal lobe C712 Parietal lobe C713 Occipital lobe C714 Ventricle NOS C715 Cerebellum NOS C716 Brain stem C717 Overlapping lesion of brain C718 Brain NOS C719 Spinal cord cranial Spinal cord C720 nerves and other Cauda equine C721 parts of the central Olfactory nerve C722 nervous system Optic nerve C723 Acoustic nerve C724 Cranial nerve NOS C725 Overlapping lesion of brain and central nervous system C728 Nervous system NOS C729 Pituitary gland Pituitary gland C751 craniopharyngeal duct Craniopharyngeal duct C752 and pineal gland Pineal gland C753 4 Not Reportable Neoplasms a Primary skin tumors C44 _ with histology codes 8000 8110 Skin Cancers Basal cell carcinoma and squamous cell carcinoma of non genital skin sites are common malignancies These tumors are not to be reported to FCDS regardless of stage All other malignant tumors of the skin must be reported including but not limited to malignant melanoma Merkel cell carcinoma lymphoma of skin and other non squamous and non basal cell skin cancers Only the following malignant neoplasms of the skin C44 0 C44 9 are not reportable M 8000 M 8005 M 8010 M 8046 M 8050 M 8084 M 8090 M 8110 Basal cell carcinoma of the skin Neoplasm malignant NOS of the skin Epithelial carcinoma NOS of the skin Papillary and squamous cell neoplasm of the skin b Carcinoma in situ of the cervix CI
38. ent has had at least one primary reportable neoplasm that is currently active or under treatment all other primary reportable neoplasms the patient has ever had active or inactive regardless of the date of diagnosis must be reported Each case of cancer must be abstracted and reported separately Information about the previous historical primary s may be sketchy The abstractor should attempt to complete an abstract with as much information as is available in the medical record If the patient does not have any reportable neoplasms active or under treatment no other primary neoplasms the patient has ever had need to be reported See Section I C Abstracting Historical Cases Optional Minimal Dataset for guidelines regarding the abstracting of historical cases in an abbreviated format g Multi Facility Reporting shared cases FCDS requires that any cancer case that meets FCDS case reporting requirements must be submitted by every facility providing services to the patient Therefore facilities that are members of shared combined or joint cancer registries and or cancer programs must report each cancer case seen in each Revised 2014 i SECTION I GUIDELINES FOR CANCER DATA REPORTING facility separately unless approved to do so by the Florida Department of Health and FCDS h Responsibility for Reporting It is the responsibility of the custodian of the medical record or the facility that is administering care to report t
39. ent of unknown and ill defined values in certain variables is a data quality indicator used to rank Florida s overall data quality and completeness of the data for each case reported and is used when comparing Florida data to other states for overall data reliability These data are also indicators of problem areas where FCDS and local registries can improve upon cancer reporting as data are available Annual AHCA Unmatched Report The AHCA Unmatched Report and subsequent follow back procedures are used to assess casefinding completeness at the facility level Consolidated AHCA and Vital Statistics Follow Back Reports Casefinding Audits Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 40 Consolidated AHCA and Vital Statistics Follow Back Reports will be available via FCDS IDEA following the June 30 Reporting Deadline Annual Bureau of Vital Statistics Unmatched Report FCDS staff will perform annual matching of the FCDS Master File to the Florida Bureau of Vital Statistics death files FCDS will provide the reporting facility with a list of unmatched Vital Statistics cases deaths that show the place of death as the reporting facility Consolidated Vital Statistics and AHCA Follow Back Reports Casefinding Audits Consolidated Reports Vital Statistics and AHCA Follow Back Reports will be available via FCDS IDEA following the June 30 Reporting Deadline FCDS EDITS Master List This is a listing of al
40. er Data System PO Box 016960 D4 11 Miami FL 33101 http fcds med miami edu inc downloads shtml International Classification of Diseases for Oncology 3 ed Geneva World Health Organization 2000 including three published errata and the 2014 ICD O 3 Update The World Health Organization WHO Publications Center USA 49 Sheridan Avenue Albany NY 12210 518 436 9686 Voice 518 436 7433 Fax ISBN 9241545348 Order Number 11503350 http www who int classifications icd en index html Current Multiple Primary and Histology Coding Rules for Solid Tumors National Cancer Institute SEER Program Bethesda MD Johnson CH Peace S Adamo P et al National Cancer Institute Surveillance Epidemiology and End Results Program Bethesda MD 2007 http seer cancer gov registrars Current Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and Hematopoietic Database desktop or web based versions available Download latest version from the National Cancer Institute SEER Program Bethesda MD http seer cancer gov registrars Current Collaborative Staging Data Collection System Coding Instructions Part I Section 1 General Instructions Part I Section 2 Tumor Markers and SSFs Part II Site Specific Schema current edition American Joint Committee on Cancer AJCC http cancerstaging org Current SEER Rx Interactive Drug Database National Canc
41. er Institute Surveillance Epidemiology and End Results Program Bethesda MD Available for download at http seer cancer gov registrars RECOMMENDED DESK REFERENCES RECOMMENDED BOOK ORDERING INFORMATION Facility Oncology Registry Data Standards FORDS current edition American College of Surgeons ACS 55 East Erie Street Chicago IL 60611 2797 312 664 4050 http www facs org cancer coc CA A Cancer Journal for Clinicians Lippincott Williams amp Wilkins Publishers P O Box 1600 Hagerstown MD 21741 9910 301 223 2300 Voice http caonline amcancersoc org Cancer Principles and Practice of Oncology g edition Lippincott Williams amp Wilkins Publishers 227 East Washington Square Philadelphia PA 19106 3780 Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 23 ISBN 10 1451105452 Cancer Registry Management Principles amp Practice for Hospitals and Central Registries 3rd Edition 2011 Kendall Hunt Publishing Company 4050 Westmark Drive PO Box 1840 Dubuque IA 52004 1840 1 800 228 0810 www kendallhunt com ncra ISBN 978 0 7575 6900 5 AJCC Cancer Staging Manual 7th ed American Joint Committee on Cancer Chicago IL Springer 2009 Edge S B Byrd D R Compton C C Fritz A G Greene F L Trotti A Eds 7th ed 2010 2010 X 646 p 130 illus With CD ROM Softcover ISBN 978 0 387 88440 0 http www springe
42. es a term that is not on the reportable list accept the reportable term and abstract the case Exception Do not abstract a case based on suspicious cytology alone The case is to be abstracted only if proven by positive cytology or other diagnostic method including a physician s clinical diagnosis See the data item Diagnostic Confirmation for methods of diagnosis Note If the word or an equivalent term does not appear on the reportable list or is not a form of a word on the reportable list the term is not diagnostic of cancer Do not report the case Forms of the word are such as Favored rather than Favor s appeared to be rather than appears Do not substitute synonyms such as supposed for presumed or equal for comparable Use these terms when screening diagnoses on pathology reports operative reports imaging scans mammograms and other diagnostic testing other than tumor markers Note If the ambiguous diagnosis is proven to be not reportable by biopsy cytology or physician s statement cancer was ruled out as diagnosis do not report the case Example Mammogram shows calcifications suspicious for intraductal carcinoma The biopsy of the area surrounding the calcifications is negative for malignancy Do not report the case Benign and borderline primary intracranial and CNS tumors Use the Ambiguous Terms that are Reportable list to identify benign and borderline primary intracranial and CNS tum
43. ete list of data items available please refer to FCDS data items list document Data on the website uses the commercial file Availability of Data by Type Media Format and Data Request Fees and Billing Procedures 1 Data CD s FCDS provides three raw data CD s a Public Use CD and two versions of the Confidential CD Please note these are flat files in a fixed layout approximately 2 million records each year therefore you will need some type of software to read in the data and analyze it i e SAS SPSS SQL FCDS will fill data requests for data CD s within 20 business days once the application has been approved and payment has been received by FCDS a The Public Use CD is available without charge to anyone requesting FCDS data The Public Use CD contains county level case data for all sites with many of the demographic variables collapsed into aggregate groups i e age race marital status etc The application form along with the variable list for the Public Use CD are available under the Data Request link on the FCDS web site http fcds med miami edu Please download the application and follow the submission instructions b The two versions of the Confidential CD are 1 The Limited Confidential CD which contains no geocoded data and 2 the Full Confidential CD containing geocoded data Both Confidential CDs are void of any personal identifiers name address date of birth and social security number The only di
44. fference between the CDs is that one contains geocodes the other does not FCDS approval is required for release of the Limited Confidential CD The application process for the Full Confidential CD requires DOH IRB approval prior to release Both Confidential CDs are available only to recognized academic research and governmental institutions There is a charge for both versions of the Confidential CD Please see the Fees and Billing Procedure section of this document for information on these charges The application forms for the Confidential CDs are available online under the Data Request link on the FCDS web site http fcds med miami edu If you would like to request one of the CDs please download this document and follow the submission instructions In addition if applying for the Full Confidential CD please note as stated above you will need to fill out the DOH IRB form as well This form is available within the Procedure Guide for studies that utilize FCDS for patient identification and contact document under the Data Request link of our website Further information on the DOH IRB application process and timeline can be found at http www doh state fl us execstaff irb index html For questions please contact Florida Department of Health Bureau of Epidemiology Cancer Registry Re Confidential Data Request 4052 Bald Cypress Way Bin A 12 Tallahassee FL 32399 1720 Telephone 850 245 4401 Fax 850 922 9299
45. he case to FCDS FCDS reviews the Agency for Health Care Administration AHCA cancer patient data annually as a retrospective quality control completeness audit The AHCA database provides an after the fact case finding mechanism ensuring cancer cases that have been reported to AHCA are also included in the FCDS database Annual Reporting Deadline June 30 The June 30 Deadline is an annual milestone for cancer reporting in Florida Florida law requires that all cancer cases diagnosed treated for cancer having a cancer related health visit while undergoing cancer treatment or having any evidence of disease at the time of encounter must be abstracted and transmitted to FCDS within 6 months of the date of first encounter for cancer FCDS reinforces the 6 month reporting standard with a June 30 Deadline each year Reporting Compliance and Data Quality Reports are run following the annual June 30 Deadline Facilities not in compliance with the 6 month reporting rule will be notified by FCDS of the delinquency Each facility will be asked to develop a remedial plan to bring the facility back into compliance with state statutes The plan must also include a statement indicating how the facility plans to stay in compliance once the current reporting year has been completed and compliance has been reached for the year in question If no action is taken or delinquency continues FCDS will notify the Florida Depa
46. hed on the FCDS website and is available for use by software vendors and other interested parties who wish to run edits prior to data submission Each record must pass all inter and intra item edits before acceptance by FCDS Records that require a NAACCR edit override FORCE will pass the edit check process and will be accepted However upon review at FCDS it may be determined the case does not meet the criteria for edit override FORCE and a Correction may be made to the case Information about Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 26 corrections to cases will be returned to the facility so you can correct your database as well For the cases requiring an edit override or Force FCDS staff will review submitted text to determine if sufficient information has been provided to override the edit in question If the information provided in text is insufficient the reporting facility will have two weeks from the time of case transmission to send FCDS the appropriate information from the path report discharge summary or other source to support the code s assigned The FCDS Quality Control Staff will use the documentation provided to validate the coding and set the relevant override flag s PSYCHIATRIC MILITARY AND VETERANS ADMINISTRATION FACILITIES United States military and Veterans Administration healthcare facilities are requested to report cancer under Rule 64D 3 006 of the Florida Administrative Code While
47. idual s FCDS Abstractor Code has been expired for greater than 2 years the individual must re apply and take and pass the New FCDS Abstractor Code Exam WHO NEEDS TO TAKE THE FCDS ABSTRACTOR CODE RENEWAL EXAM Y Individuals with an ACTIVE not yet expired FCDS Abstractor Code will be required to take and pass the FCDS Abstractor Code Renewal Exam once their code has expired Y Individuals with an EXPIRED FCDS Abstractor Code will be required to take the FCDS Abstractor Code Renewal Exam each year in order to keep their FCDS Abstractor Code current and to renew their individual FCDS Abstractor Code annually gt Registrars will be required to navigate use and apply standard cancer registry desk and electronic desktop or web based references and resources to pass the examination gt References used include but are not limited to Current FCDS DAM Current MPH Rules for both Solid Tumors and Hematopoietic and Lymphoid Neoplasms Collaborative Stage Data Collection Rules and Schema including Site Specific Factors SEER Rx the Hematopoietic Database and SEER Self Instructional Manuals including Books 2 3 4 gt Examinations are timed with a maximum of 1 hour allowed to take the annual renewal exam 15 Q amp A and 2 hours allowed for initial exam 20 Q amp A gt The registrar will be given two opportunities to successfully pass the examination with a score of 80 or greater gt If the registrar fails twice s he must wait at
48. ing the histology and behavior malignant diagnosed on or after 01 01 2001 with the 2001 or later diagnosis date If the diagnosis date of a hematopoietic disease is unknown and the admission date is 01 01 2001 or later the case is reportable using ICD O 3 reporting criteria Please refer to the FCDS Rules for Reporting Hematopoietic Diseases in Section II for specific instructions on reporting hematopoietic diseases Benign and borderline brain and central nervous system tumors are reportable even if they were diagnosed prior to 1 1 04 and the patient has another active reportable neoplasm Squamous Intraepithelial Neoplasia Grade III of vulva vagina and anus are reportable as historical cases even if they were diagnosed prior to 01 01 2001 and the patient has another active reportable neoplasm 5 Abstracting Historical Cases Optional Minimal Dataset Historical case refers to a primary reportable neoplasm malignant or benign borderline brain CNS tumors that it is not active no evidence of disease and currently not receiving any treatment AND the patient is seen at the reporting facility for another cancer benign reportable neoplasm that is active and or undergoing treatment There are two methods for reporting a Historical Case FCDS will accept historical cases reported as full abstracts or historical cases reported using the minimal dataset below a For every abstract submitted the record layout will allow for the entry of
49. ion centers day surgery and other ambulatory care outpatient departments including outpatient diagnostic radiology and laboratory service areas and emergency rooms are additional casefinding sources for patients seen only in an ambulatory care setting Unified Billing System Reports also can be used to identify these cases 5 Diagnostic Imaging Radiology Department New patient registration rosters for patients receiving diagnostic imaging services x ray CT scan PET scan MRI or other imaging are an excellent source for identifying new cancer cases Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING ICD 9 CM CASEFINDING LIST FOR REPORTABLE TUMORS JULY 2014 The following ICD 9 CM list is to be used to identify potentially reportable tumors Some ICD 9 CM codes contain conditions that are not reportable These records still need to be reviewed and assessed individually to verify whether or not they are reportable to FCDS ICD 10 CM will be implemented 10 1 2015 in the U S A Required for review Optional for review 042 AIDS review cases for AIDS related malignancies 140 0 209 36 Malignant neoplasms excluding skin 173 0 173 9 with morphology codes 8000 8110 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 pineal body and othe
50. ioner says the patient has a cancer or carcinoma or when the patient is undergoing treatment for cancer that may not have been histologically or otherwise confirmed A clinical diagnosis may be recorded as part of the final diagnosis on the face sheet or other parts of the medical record See Note and Exceptions below Note A pathology report normally takes precedence over a clinical diagnosis If the patient has a negative biopsy the case would not be reported Exception 1 If the physician treats a patient for cancer in spite of the negative biopsy abstract and report the case Exception 2 If enough time has passed that it is reasonable to assume that the physician has seen the negative pathology but the clinician continues to call this a reportable disease accession the case A reasonable amount of time would be equal to or greater than 6 months c Ambiguous Terminology As part of the registry case finding activities all diagnostic reports should be reviewed to confirm whether a case is reportable This includes pathology reports bone marrow biopsy reports autopsy reports diagnostic imaging reports and results from medical testing If the terminology describing the diagnostic assessment is ambiguous use the following guidelines to determine whether a particular case should be abstracted and reported to FCDS Words or phrases that appear to be synonyms of these terms do not constitute a diagnosis For example likely alone doe
51. iries to the FCDS Master File when data requests are made Any unusual data will be reviewed and facility abstracting staff may be requested to review individual cases to confirm the reporting of certain data items Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 35 12 Facility Evaluation Report The report is a graphical and numerical representation of the performance of a reporting facility over a given time period detailing the three principles of data appraisal Timeliness Completeness and Accuracy 13 FCDS Data Quality Indicator Report DQIR The FCDS Data Quality Indicator Report is designed to provide feedback to registries on the completeness of case abstracts by examining the frequency of coding unknown or ll defined values in key analytic data items Data must meet rigorous national quality standards to be included in local regional state and national cancer rates reports to Congress numerous surveillance related publications and for registry certification The percent of unknown and ill defined values is an indicator used in ranking Florida s overall data quality and completeness of case reporting and is used when comparing Florida data to other states for overall data validity and reliability These data are also early indicators of problem areas and areas where FCDS and local registries can improve upon cancer reporting as data are available The report includes the Fl
52. ished resources and statistics are available on the FCDS website http fcds med miami edu inc statistics shtml If a data request does not fall into any of the above categories please contact us at 1 800 906 3034 or 305 243 4600 All media requests should be directed to Irv Kokol of the FL DOH Office of Communications at 850 245 4111 FCDS maintains a list of all published articles using FCDS Data Please provide information on any scientific publications resulting from a data request FCDS MANAGEMENT REPORTS FCDS Quarterly Activity Status Report This report summarizes the FCDS file activity for each facility on a quarterly basis Every facility should have some file activity during every quarter of the year The report documents information about the number and quality of cases submitted during the previous quarter timeliness of reporting and also provides an annual incidence and completeness summary which compares observed to expected numbers of cases reported for the year See Forms Section FCDS Data Quality Indicator Report This report is a scaled down model of a similar report the CDC National Program of Cancer Registries NPCR provides to Florida and each NPCR state as an assessment of state wide data The report reflects 5 years of data and examines the frequency of assignment of unknown or ill defined values to key analysis variables over the course of the five year period with comparison to national The perc
53. ithelial Neoplasia VIN IID are reportable to FCDS and should be included in casefinding activities ii Pancreatic Intraepithelial Neoplasia PAIN III is reportable to FCDS histology 8148 2 and should be included in casefinding activities Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 3 iii Glandular Intraepithelial Neoplasia Grade I I High Grade Glandular Dysplasia is reportable as adenocarcinoma in situ of the esophagus with histology code 8148 2 iv In Utero Diagnosis and Treatment beginning in 2009 diagnosis and treatment dates for a fetus prior to birth are to be assigned the actual date of the event In the past those dates were set by rule to the date the baby was born The exact date may be used for cases diagnosed prior to 2009 and must be used for cases diagnosed 1 1 2009 and later v New terminology may be used by your local pathologist to describe malignant or in situ neoplasms i e well differentiated neuroendocrine neoplasm When this occurs the neoplasm is reportable to FCDS Note 1 AJCC TNM Manual 7 edition states for Esophageal Cancers High grade dysplasia includes all non invasive neoplastic epithelia that was formerly called carcinoma in situ a diagnosis that is no longer used for columnar mucosae anywhere in the gastrointestinal tract Therefore all high grade severe dysplasia of esophagus are reportable as carcinoma in situ Note 2 AJCC TNM Manual 7 edition states for Col
54. l FCDS edits included in the latest FCDS EDITS Metafile and includes the edit number edit category and edit message The current list can be found under Downloads on the FCDS website This list is updated regularly and can be found on the FCDS Website under Downloads AWARDS Jean Byers Memorial Award for Excellence in Cancer Registration Pat Strait Award for Excellence in Cancer Registry Abstracting formerly known as Certificate of Excellence in Cancer Reporting The Pat Strait Award for Excellence in Cancer Registry Abstracting is awarded to individuals who contribute to a facility achieving the annual Jean Byers Memorial Award Criteria for receipt of the Jean Byers Award and the Pat Strait Award are based on a standard set of criteria that meet or exceed the completeness timeliness and accuracy requirements determined by FCDS and CDC The criteria may change between years depending on annual reporting conditions but generally are a factor of a combination of successful data quality metrics including Reporting Deadline percent of missed cases as determined using AHCA and Vital Statistics Matching and Follow Back Results missed cases cannot exceed 10 of the facility s annual caseload and other established data quality indicator metrics FCDS GENERAL MAILING INSTRUCTIONS DO NOT MAIL ANY MATERIALS CONTAINING PERSONAL HEALTH INFORMATION PHD In order to protect and properly handle all packages FCDS is making the following rec
55. le List as an electronic file embedded within their software such as a suspense case and should include comments that the registrar reviewed the medical record and determined that the case does not meet reportable criteria The suspense case should include documentation as to why the facility will not report the case either in text and or using the FCDS AHCA Disposition Codes below Description Reportable Missed Case Case to be Abstracted amp Reported by Facility NIR Tumor was Not Malignant Behavior 0 or 1 N R NonReportable Skin Cancer Site C44 and Morph 8000 to 8110 NIR No Evidence of Cancer at This Time NED NIR Consultation Only N R Cancer Not Proven Equivocal Case Previously Reported to FCDS by this Facility N R Outpatient Record with No Active Cancer Documented in Record NIR Insitu Cancer of Cervix or CIN III NIR Other Reportable Case Abstraced BUT Not found in FCDS files Abst Requested NIR No Cancer Mentioned in Medical Record Skins we elected not to FB since most of them tum out N R NIR Hematopoietic Diseases Dx Prior to 2001 NIR Case DX Prior to FCDS Reference Date Same Cancer Same Facility NIR Benign or Borderline Brain CNS Tumor Dx Prior to 2004 Unknown if Reportable No Record of this Patient at this Facility Unknown if Reportable Lost Medical Record Unknown if Reportable No Follow Back Ever Returned by this Facility NIR Special Case Other Hospice Case Not A Hospital Tr
56. mear of cervix with cytologic evidence of malignancy 795 16 Papanicolaou smear of vagina with cytologic evidence of malignancy 796 76 Papanicolaou smear of anus with cytologic evidence of malignancy 999 81 Extravasation of vesicant chemotherapy V07 31 V07 39 Other prophylactic chemotherapy V07 8 Other specified prophylactic measure Personal history of malignancy review these for recurrences subsequent primaries and or V10 0 V10 9 subsequent treatment V42 81 V42 82 Organ or tissue replaced by transplant Bone marrow transplant V58 0 Encounter for radiotherapy V58 1 Encounter for chemotherapy and immunotherapy V58 11 Antineoplastic Chemotherapy V58 12 Antineoplastic Immunotherapy V66 1 Convalescence following radiotherapy V66 2 Convalescence following chemotherapy V67 1 Radiation therapy follow up V67 2 Chemotherapy follow up V71 1 Observation for suspected malignant neoplasm V76 0 V76 9 Special screening for malignant neoplasm V87 41 Personal history of antineoplastic chemotherapy Note Pilocytic juvenile astrocytoma M 9421 is reported with the behavior coded 3 9421 3 not 9421 1 Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING ICD 10 CM CASEFINDING LIST FOR REPORTABLE TUMORS JULY 2014 The following ICD 10 CM list is to be used to identify potentially reportable tumors Some ICD 10 CM codes contain conditions that are
57. ncludes o Patient name address including street city county zip code and equivalent geo codes Name of relatives Name of employers All elements of date pertaining to patient ex admission discharge and birthdate Telephone numbers Fax numbers Electronic email addresses Social Security number medical record number Health plan beneficiary number Account number Certificate and license number Any vehicle or other device serial number Web Universal Resource Locator URL Internet Protocol IP address number Finer or voice prints Photographic images OONO Or OC 30 59 102 OOOO Or O Admissions by Facilities Report FCDS Data Acquisition staff will review the Admissions by Facilities Report an internal FCDS report on a regular basis This report makes a comparison of observed to expected numbers of cases reported by each facility for any time period requested The report is based on a five year historical summary of cases reported to FCDS by each facility The ratio of observed to expected is reported as a percent of completeness Either FCDS Staff or a representative of the Department of Health will notify facilities that have not reported the expected number of cases These same data are included in the Quarterly Activity Report Facility Timeliness Report FCDS Data Acquisition staff will review the Facility Timeliness Report on a regular basis This report shows the average amount of time in days that it takes the repor
58. not reportable These records still need to be reviewed and assessed individually to verify whether or not they are reportable to FCDS ICD 10 CM will be implemented on 10 1 2015 in the U S A Required for review Optional for review SEER publishes a complete list of optional codes C00 _ C43 _ Malignant neoplasms excluding skin C44 0 C44 9 with morphology codes 8000 8110 C45 _ C96 ___ Malignant neoplasms excluding skin C44 0 C44 9 with morphology codes 8000 8110 D00 _ D09 _ Carcinoma in situ exclude skin cervix and prostate in situ D04 _ D06 _ and D07 5 D18 02 Hemangioma of intracranial structures D18 1 Lymphangioma any site brain other parts of CNS D32 _ Benign neoplasm of meninges cerebral spinal and unspecified D33 _ Benign neopl asm 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 N eoplasm of uncertain or unknown behavior of pituitary gland craniopharyngeal duct and pineal gland D45 Polycythemia vera 9950 3 D46 _ Myelodysplastic syndromes 9980 9982 9983 9985 9986 9989 9991 9992 D47 1 Chronic myeloproliferative disease 9960 9963 D47 3 Essential hemorrhagic thrombocythemia 9962
59. ns with a variable mix of content questions weighted differently depending on whether this is an exam for a New FCDS Abstractor Code or Renewal of an existing FCDS Abstractor Code Questions are electronically selected at random from a pool of nearly 300 questions covering 6 major topic areas No two exams will be alike The 6 topic areas include General Abstracting Knowledge General Abstracting Rules and Florida Specific Rules Primary Site Histology Grade Stage at Diagnosis Latest Rule Changes Treatment and Survival Standard References Used for Testing e FCDS DAM current version e ICD O 3 including errata and updates e MPH Rules for Solid Tumors current e MPH Rules Database for Hematopoietic Lymphoid Neoplasms current e Collaborative Stage Data Collection System to be changed to TNM and SS2000 Part I Section 1 General Instructions 0 Part I Section 2 Lab Tests Tumor Markers SSF Notes gt Part II Site Specific Schema e SEER Rx current e SEER Self Instruction Manuals basics Book 2 Cancer Characteristics Book 3 Tumor Registrar Vocabulary Composition of Medical Terms Book 4 Human Anatomy as Related to Tumor Formation Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 33 WHO NEEDS TO TAKE THE FCDS ABSTRACTOR CODE EXAM v Individuals hoping to acquire a NEW FCDS Abstractor Code will need to take the New FCDS Abstractor Code Exam v Ifan indiv
60. ommendations 1 We ask that if you are mailing a package to FCDS use Federal Express UPS Airborne Express or any other type of courier service a The FCDS street address below must be used for courier packages FCDS University of Miami School of Medicine 1550 NW 10 AVE Room 410 Miami FL 33136 Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 41 Include the following text on a separate header page in the package Always request a signature upon delivery c Make sure that the addressee at FCDS knows that she he is to expect a package d Track the package to ensure that it has reached its destination You may want to explore the e mail tracking and notification features that the courier of choice offers 2 For non confidential information if using US Postal Service which may include Express mail Priority mail and Certified mail you must use the FCDS PO Box address below FCDS University of Miami School of Medicine PO BOX 016960 D4 11 Miami FL 33101 3 All shipments must adhere to the FCDS Confidential Information Security Policy CALENDAR FORMS TEMPLATES SAMPLE REPORTS FCDS Annual Reporting Calendar FCDS 2014 Abstract Form Sample FCDS Discrepancy Journal Sample Not Reportable List Template FCDS Quarterly Activity Status Report Sample FCDS Data Quality Indicator Report Sample Revised 2014
61. on Cancers The terms high grade dysplasia and severe dysplasia may be used as synonymous for in situ adenocarcinoma and in situ carcinoma These cases should be assigned a pTis It is necessary to contact your pathologist and or cancer committee to determine if s he applies this definition to all colon cancers If so high grade severe dysplasia of any colon site is reportable as carcinoma in situ b Specified malignant neoplasms of the skin dermatofibrosarcoma protuberans Kaposi sarcoma malignant melanoma merkel cell carcinoma mycosis fungoides sebaceous adenocarcinoma and sweat gland adenocarcinoma are reportable conditions c Gastro intestinal stromal tumors GIST and thymomas are often non malignant However they must be abstracted and assigned a Behavior Code of 3 if they are noted to have multiple foci metastasis or positive lymph nodes or there is other evidence of malignancy noted by surgeon pathologist or during clinical workup following initial diagnosis d Basal and squamous skin cancers in genital sites histology codes 8000 8110 are reportable Genital Sites include the following anatomic locations C51 0 C51 1 Labia C51 2 Clitoris C51 8 C51 9 Vulva C52 9 Vagina C60 0 Prepuce C60 9 Penis C63 2 Scrotum d Benign and Borderline Cancers Benign and borderline primary intracranial and central nervous system CNS tumors with a behavior code of 0 or 1 in ICD O 3 are reporta
62. on for data release from each of the medical facilities of interest prior to making the data request Keep in mind that all applicable fees apply The exception to the above rule is when requesting data submitted from the originating institution Each reporting facility has an annual 300 credit which can be applied to data requests only with regard to data submitted from their institution Requests should be submitted in writing on facility letterhead and signed by the supervisor or the administrator listed in the FCDS database If the data is to be sent to a third party this request should be specified in the letter Data are extracted from two main files the master file and the commercial file The master file is a data file containing all cancer records that have successfully passed the SEER Surveillance Epidemiology and End Results National Cancer Institute program and FCDS standard edit checks This file is continually updated as new records are received The commercial file is a snapshot of the master file at the exact moment it is created therefore it remains static while the master file is Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 36 dynamic Depending on the nature of the request FCDS will determine from which file to extract the data Generally the commercial file is used to fill requests for incidence data because the data are relatively static and menu rates are calculated from this file For a compl
63. on via FCDS sponsored training programs NAACCR Webinars FCDS web based training modules teleconferences FCDS web broadcasts or recorded educational events and programs All FCDS originated training materials and web broadcasts are recorded and available free on the FCDS website d Provide specific routine reports to verify data submission and resolve data discrepancies oP 2 Training and Education FCDS develops teaches and supports a full range of Education and Training Options including o FCDS educational web broadcasts are organized up to 6 times a year or as needed o The FCDS On Line web based Abstractor Training Course consisting of 20 modules and 1000 informational slides with voice over recordings and testing is available on the FCDS website o FCDS hosts 12 NAACCR Educational Webinars at 7 host sites around the state each year o Additional resources are available and advertised through the FCDS Memo and via blast e mail 3 Quality Control The primary objective of the Florida Cancer Data System FCDS is to maintain a high quality database of useable timely complete and accurate data for every case of cancer identified in the state of Florida a Completeness is the extent to which all required cases have been reported to FCDS Completeness is assessed using i Historical data from facilities ii On Site or Remote Access Casefinding Audits iii Annual Linkage to Florida s Agency for Health Care Administration state
64. onsistently or out of synch with national reporting standards and guidelines On Site or Remote Access Re Abstracting Audits The FCDS Quality Control staff and or outside contract agents working on behalf of FCDS will perform on site or remote access review of abstracting procedures by auditing individual reports and or entire medical records of cases previously submitted to FCDS The data validation or re abstracting audit serves to verify that coded data submitted to FCDS can be validated when compared to original source documents at the hospital or central registry level Discrepant data are followed back to the originating institution for clarification Reconciliation of the Re abstracting Audit Key data items will be evaluated and any discrepancy noted between the auditor s findings and the original abstract findings will be returned to the facility for reconciliation If the auditor s findings are disputed documentation must be submitted to clarify the originally abstracted codes These audits allow assessment with regard to standardized interpretation of data definitions coding rules and guidelines policies and procedures and serve to identify areas that may require further education and training Remote Access Re Abstracting Audits Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 32 FCDS may substitute On Site Re Abstracting Audits with Remote Access Re Abstracting Audits Should FCDS decide to perf
65. orida state and National distribution of unknown value used for comparison The report uses data from analytic cases only Note This report is a scaled down model of a similar report the CDC National Program of Cancer Registries NPCR provides to Florida and each NPCR state as an assessment of our State wide data 4 Data Requests Filing the appropriate FCDS and DOH forms is required for data requests The forms are available on the FCDS website http fcds med miami edu inc datarequest shtml Requests for special reports involving release of personal identifiers will be reviewed by a data use committee of DOH for cost effectiveness research worthiness and to ensure patient confidentiality In general most requests for data fall into five categories CD s with raw non confidential data statistical tabular data confidential data data linkages and data for investigation of potential cancer clusters There are specific procedures for data release based on the category of request and associated fees All data requests regardless of the nature of the request must be submitted to FCDS in writing Reporting facility data is considered confidential data When requesting facility specific data data other than that submitted from your facility please mail the data request form along with original cover letters from all concerned facilities on their facility letterhead to FCDS It is the requestors responsibility to obtain permissi
66. orm Remote Online audits facilities will be asked to make available pertinent reports from medical records and or other data sources to FCDS for review or FCDS will utilize existing source documents used in routine reporting FCDS Abstractor Code Policy Every registrar abstractor planning to work in the State of Florida is required to obtain an individual FCDS Abstractor Code This code is assigned by FCDS to persons who successfully pass the FCDS Abstractor Code On Line Examination regardless of certification by NCRA as a CTR experience in the registry industry or other factors As of January 1 2013 any individual planning to acquire a New FCDS Abstractor Code or planning to Renew an Existing FCDS Abstractor Code must take and pass the FCDS Abstractor Code Exam Registration for testing and real time on line testing can be found on the FCDS website The FCDS Abstractor Code Requirement has been FCDS Policy for many years and applies to every cancer registrar working in the state of Florida CTR or non CTR Florida resident or out of state contractor regardless of number of years experience FCDS will not accept cases from individuals without an Active Current FCDS Abstractor Code While the FCDS Abstractor Code Requirement Policy remains unchanged the FCDS Abstractor Code Exam is a new tool introduced to help FCDS expedite FCDS Abstractor Code approvals renewals and monitoring Exams are short 15 20 multiple choice or T F questio
67. ors that are reportable If any of the reportable ambiguous terms precede either the word tumor or the word neoplasm the case is reportable Abstract and report the case Example The mass on the CT scan is consistent with pituitary tumor Abstract and report the case Discrepancies If one section of the medical record s uses a reportable term such as apparently and another section of the medical record s uses a term that is not on the reportable list accept the reportable term abstract and report the case Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING Exception Do not abstract a case based only on suspicious cytology without additional confirmation of the presence of disease The case is abstracted and reported if proven by positive cytology or other diagnostic methods including a physician s clinical diagnosis See the data item Diagnostic Confirmation for methods of diagnosis Note If the word or an equivalent term does not appear on the reportable list or is not a form of a word on the reportable list the term is not diagnostic of cancer Do not abstract the case Forms of the word are such as Favored rather than Favor s appeared to be rather than appears Do not substitute synonyms such as supposed for presumed or equal for comparable e Use these terms when screening diagnoses on pathology reports scans ultrasounds and other diagnostic testing other than tumor ma
68. out additional information The following modifying terms when applied to a malignancy should NOT be considered diagnostic of cancer without additional information such as treatment for cancer Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 7 Cannot be ruled out questionable equivocal rule out possible suggests potentially malignant worrisome Positive molecular marker or cytogenetic testing in the absence of pathologic or clinical evidence of reportable disease are indicative of risk only and do not constitute a diagnosis In Situ and Invasive Behavior codes 2 and 3 If an ambiguous term s precede a word that is synonymous with an in situ or invasive tumor e g cancer carcinoma malignant neoplasm non invasive cancer etc the case is reportable Abstract and report the case Example The pathology report says Prostate biopsy with markedly abnormal cells that are typical of adenocarcinoma Abstract and report the case Negative Example The final diagnosis on the outpatient report reads Rule out leukemia Do not abstract or report the case Do track that you reviewed the record and deemed the case not reportable Be sure to include the reason the case is not reportable to FCDS so you do not have to re review the case during the annual AHCA casefinding audit Discrepancies If one section of the medical record s uses a reportable term such as apparently and another section of the medical record s us
69. pital O a 4 Abstracting Non Analytic and Historical Cases Although the Commission on Cancer American College of Surgeons COC AcoS does not require accredited facilities to abstract non analytic or historical cases a population based cancer registry such as FCDS must record ALL cancers meeting the FCDS reporting requirements regardless of class of case place of diagnosis or date of diagnosis FCDS realizes that much of the information about the original diagnosis staging and treatment of non analytic and historical cancers may be unavailable or incomplete The abstractor should attempt to complete each abstract with as much information as is available in the medical record a The following morphology codes are reportable as historical cases if they were diagnosed prior to 1 1 01 and the patient has another active reportable neoplasm These neoplasms were historically Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 20 reported with behavior 1 borderline malignancy They were changed to behavior 3 malignant when ICD O 3 was released in 2001 This change in reporting rules is consistent with ICD O 3 8931 3 9960 3 9981 3 9989 3 9393 3 9961 3 9982 3 9538 3 9962 3 9983 3 9950 3 9980 3 9984 3 If a patient diagnosed with any of the above hematopoietic disease morphology codes prior to 01 01 2001 undergoes transformation to another hematopoietic disease before 01 01 2010 enter the case into the registry us
70. r com American Cancer Society Textbook of Clinical Oncology American Cancer Society Vermont Division Inc 13 Loomis Street Montpelier VT 05602 1 800 227 2345 1 800 ACS 2345 http www cancer org Registry Plus Online Help Download the free desktop reference Registry Plus Online Help at http www cdc gov cancer npcr Online Help is an interactive tool that incorporates many of the references above and is maintained by the CDC The Registry Plus Online Help application includes fully indexed versions of the FORDS Manual Collaborative Stage and Multiple Primary and Histology Coding manuals as well as the NAACCR Data Dictionary the SEER Coding Manual and the CD O 3 NAACCR Standards for Cancer Registries Volume IT Data Standards and Data Dictionary current edition North American Association of Central Cancer Registries Inc NAACCR 2121 West White Oaks Drive Suite B Springfield Illinois 62704 7412 Phone 217 698 0800 Fax 217 698 0188 http www naaccr org SEER Self Instructional Manuals 1 4 7 Book 1 Objectives and Functions of a Tumor Registry 1999 Book 2 Cancer Characteristics and Selection of Cases 1991 Book 3 Tumor Registrar Vocabulary The Composition of Medical Terms 1992 Book 4 Human Anatomy as Related to Tumor Formation 1995 Book 7 Statistics Epidemiology for Cancer Registries 1994 National Cancer Institute Publications Ordering Service
71. r intracranial endocrine related structures 227 9 Benign neoplasm endocrine gland site unspecified 228 02 Hemangioma of intracranial structures 228 1 Lymphangioma any site brain other parts of CNS 230 0 234 9 Carcinoma in situ exclude skin cervix and prostate in situ 232 0 232 9 233 1 233 4 235 0 239 9 Neoplasms of uncertain behavior 236 0 Endometrial stroma low grade 8931 3 237 0 237 9 Neoplasm of uncertain behavior borderline of endocrine glands and nervous system 238 4 Polycythemia vera 9950 3 238 6 238 79 Other lymphatic and hematopoietic tissues 239 6 239 89 Neoplasms of unspecified nature 258 02 258 03 Multiple endocrine neoplasia MEN type IIA and IIB 273 2 Other paraproteinemias 273 3 Waldenstrom s macroglobulinemia 9761 3 285 22 Anemia in neoplastic disease 288 3 Hypereosinophilic syndrome 9964 3 288 4 Hemophagocytic syndromes 9751 3 9754 3 289 6 Familial Polycythemia 289 83 Myelofibrosis NOS 9961 3 338 3 Neoplasm related pain acute chronic Cancer associated pain 511 81 Malignant pleural effusion code first malignant neoplasm if known 692 7 Malignancy due to solar radiation 9725 3 hydroa vacciniforme like lymphoma 758 0 Myeloid leukemia associated with Down Syndrome 789 51 Malignant ascites code the first malignant neoplasm if known 795 81 795 89 Abnormal tumor marker 795 06 Papanicolaou s
72. rkers Note If the ambiguous diagnosis is proven to be not reportable by biopsy cytology or physician s statement do not abstract or report the case d Outpatient Ambulatory Care Only Cases There must be sufficient documentation in the medical chart positive radiology report positive pathology report physician statement etc that definitively establishes that the patient either has active malignancy and or is currently undergoing therapy for malignancy If insufficient documentation exists in the medical chart do not abstract the case e Non Analytic Cases The American College of Surgeons Commission on Cancer does not require accredited facilities to abstract non analytic cases However FCDS does require the collection and reporting of ALL cases that meet the FCDS reporting requirements regardless of Class of Case f Historical Cases The American College of Surgeons Commission on Cancer does not require accredited facilities to abstract historical cases However FCDS does require the collection and reporting of certain historical cancers even when the patient has no evidence the historical cancer is active Patients diagnosed with any cancer during their lifetime are many times more likely to develop new cancers It is important for researchers to know the number and types of any and all cancers each patient has had during his her lifetime in order to effectively research and evaluate cancer incidence If a pati
73. rtment of Health that the facility is non compliant and further action will be taken Any remediation or other action plan must be approved by the Florida Department of Health and FCDS FCDS will monitor the plan Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING Table A NAACCR Layout Version 14 Comparison of Reportable Cancers FCDS CoC and NPCR FCDS CoC NPCR Reportable Diagnoses 1 Behavior code of 2 or 3 in ICD O 3 includes VIN III VAIN M AIN M 2 Non malignant behavior codes 0 and 1 primary intracranial and central nervous system tumors including juvenile astrocytoma M9421 3 for primary sites as defined in the Table Primary Site Codes for Non Malignant Primary Intracranial and Central Nervous System Tumors 1 Behavior code of 2 or 3 in ICD O 3 or for 2010 and later diagnoses behavior code 3 according to the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues 2008 39 2 Non malignant behavior codes 0 and 1 primary intracranial and central nervous system tumors including juvenile astrocytoma M9421 3 for primary sites as defined in the Table Primary Site Codes for Non Malignant Primary Intracranial and Central Nervous System Tumors 1 Behavior code of 2 or 3 in ICD O 3 includes VIN M VAIN M AIN IID 2 Non malignant behavior codes 0 and 1 primary intracranial and central nervous system tumors including juvenile astrocytoma M
74. ry and Histology Coding Rules for Solid Tumors The 2007 Multiple Primary and Histology Coding Rules for solid tumors contain site specific rules for lung breast colon melanoma of the skin head and neck kidney renal pelvis ureter bladder and malignant and nonmalignant brain primaries A separate set of rules addresses the specific and general rules for all other solid tumor sites And a special set of rules has been written for hematopoietic and lymphoid neoplasms The multiple primary rules guide and standardize the process of determining the number of primary tumors or abstracts to be created The histology rules contain detailed histology coding instructions Registrars must refer to the 2007Multiple Primary and Histology Coding Rules for general and cancer site specific instructions More information on these rules can be found on the NCI SEER website at http seer cancer gov tools mphrules index html 2014 Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Rules and Heme DB The Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the accompanying Hematopoietic Database replaced the February 2001 Single Versus Subsequent Primaries of Lymphatic and Hematopoietic Disease rules and foldout table An on line version of the new rules and database is available at http seer cancer gov seertools hemelymph A desktop version is available for download at http seer cancer gov tools heme Please be sure to use th
75. s not constitute a diagnosis In the absence of more definitive evidence the following modifying terms when applied to a neoplasm should be interpreted as diagnostic of cancer Apparent lee consistent with neoplasm suspicious for Appears favor s presumed tumor comparable with malignant appearing probable typical of compatible with most likely suspect ed use of the terms neoplasm and tumor begin with cases diagnosed 1 1 2004 and later and are to be used in conjunction with nonmalignant benign or borderline ICD O 3 behavior codes 0 or 1 primary intracranial and central nervous systems only C70 0 C72 9 C75 1 C75 3 While consistent with can indicate involvement neoplasm without specification of malignancy is not diagnostic except for non malignant primary intracranial and central nervous system tumors Exception If cytology is reported as suspicious abstract the case only if a positive biopsy or a physician s clinical impression of cancer supports the cytology findings Examples of Diagnostic Terms Example 1 The inpatient discharge summary documents a chest x ray consistent with carcinoma of the right upper lobe The patient refused further work up or treatment Consistent with carcinoma is indicative of cancer Example 2 The mammogram report states suspicious for malignancy Suspicious for malignancy is indicative of cancer Ambiguous Terms That Do Not Constitute a Diagnosis with
76. specimens collected from patient encounters within the state of Florida MUST electronically submit the specified data for every malignant cancer case Complete information reporting specifications and pathology lab case report record layout can be found on the FCDS website at http fcds med miami edu Each pathology laboratory has multiple submission choices generating a tab delimited file from their existing database using the web based software provided by FCDS generating an HL7 formatted file for download or generating an HL7 formatted file for transmission using PHINMS Click on the PATH LAB icon then scroll down to the Path Labs File Layout The document describes in detail the various formats that are acceptable to FCDS The rest of the PATH LAB page includes important information for reference including the NAACCR FCDS cancer terms SNOMED codes and ICD 9 code files you should use to filter and select only the lab records that identify cancer as specified in these standard files FCDS RESPONSIBILITIES 1 Data Acquisition Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 28 In order to support the data acquisition aspect of the statewide registry FCDS will Provide manuals which specifically define data collection and reporting requirements Provide a data collection tool s and user manual s for electronic web based data submission c Train facility staff and interested parties in incidence data collecti
77. t Policy remains unchanged the FCDS Abstractor Code Exam is a new tool introduced to help FCDS expedite FCDS Abstractor Code approvals renewals and monitoring Exams are short 15 20 multiple choice or T F questions with a variable mix of content questions weighted differently depending on whether this is an exam for a New FCDS Abstractor Code or Renewal of an existing FCDS Abstractor Code Questions are electronically selected at random from a pool of nearly 300questions covering 6 major topic areas No two exams will be alike The 6 topic areas include General Abstracting Knowledge General Abstracting Rules and Florida Specific Rules Primary Site Histology Grade Stage at Diagnosis Latest Rule Changes Treatment and Survival Standard References Used for Testing e FCDS DAM current version ICD O 3 including errata and updates MPH Rules for Solid Tumors current MPH Rules Database for Hematopoietic Lymphoid Neoplasms current Collaborative Stage Data Collection System changes to TNM and SS2016 in 2015 2016 Part I Section 1 General Instructions Part I Section 2 Lab Tests Tumor Markers SSF Notes Part Il Site Specific Schema e SEER Rx current e SEER Self Instruction Manuals basics gt Book 2 Cancer Characteristics gt Book 3 Tumor Registrar Vocabulary Composition of Medical Terms gt Book 4 Human Anatomy as Related to Tumor Formation WHO NEEDS TO TAKE THE FCDS ABSTRACTOR COD
78. t abstracting agency or individual within or outside the state of Florida CONFIDENTIALITY Patient information personal health information medical records and healthcare facility data are all confidential and continue to be a concern with regard to cancer and other disease reporting Please do not fax or email patient information to FCDS Also please take care when discussing cases over the phone with FCDS staff DO NOT E MAIL FAX OR MAIL PATIENT INFORMATION PHI TO FCDS UNDER ANY CIRCUMSTANCES unless you are provided specific instructions for using our Secure Fax Service A CASE ELIGIBILITY Florida facilities are legislatively mandated to report any case of cancer meeting the Florida cancer definition regardless of facility or network affiliation or Class of Case FCDS requires complete abstracting of cancer cases that the Commission on Cancer American College of Surgeons may not require If your facility participates in the diagnosis staging treatment or continuing care of a patient during the first course of treatment progression of disease or disease recurrence the case must be reported to FCDS If any diagnostic staging or other evaluative studies are conducted at your facility diagnostic imaging re biopsy sentinel node biopsy surgical resection or other staging or treatment etc your facility must report the case regardless of the Class of Case Consult Only cases MAY be an exception to reporting A consul
79. t only case is any case where the facility provides a second opinion or review of earlier studies without additional testing at your facility A second opinion may include re reading pathology slides or re reading diagnostic imaging studies If your facility does not perform any additional testing the case may not be reportable to FCDS However if you facility does any additional testing for this or any other cancer and they have evidence of disease or are undergoing treatment for cancer the case is reportable Exception 1 Patients undergoing planned first course or later course hormonal treatment for breast or prostate cancer that continue to demonstrate no active neoplasm should not be reported Any patient with active malignancy any evidence of disease must be reported Exception 2 Patients seen in an ambulatory care setting for port a cath placement where no chemotherapeutic or anti neoplastic agent s is injected into the port do not need to be reported However many Florida healthcare facilities including Commission on Cancer American College of Surgeons accredited cancer programs continue to report these cases as part of monitoring the full continuum of patient care Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING Please note that many types of drugs may be administered through a port a cath delivery system The medical record and medication flow sheets MUST be reviewed and cannot include administration of
80. that may require additional training The QC Abstract Review Case Selection Process is fully automated and randomly selects one of every 25th record processed which accounts for nearly 4 of cases being visually reviewed for accuracy Each case selected is placed in a QC file ready for visual review by the FCDS QC staff Records with discrepant data must be resolved by the reporting facilities through FCDS IDEA by making return comments on each case agree disagree add documentation to support original coding other rationale The case is then reviewed again by FCDS QC staff different staff than the original FCDS Reviewer and a final decision is made based on all information available This three step process provides the registry every opportunity to rebut identified errors or deficiencies in the abstract by having three CTR or CTR eligible staff review each case and provide documented input to what they interpret from the documentation provided in the original abstract This process also serves as an educational tool for new and experiencedO registrars regarding where they have deficiencies in their abstracting tool kit and what they should be doing when abstracting specific cases by providing comment on a case by case basis Registry Managers should always share results with staff member responsible for the original abstract Otherwise they will continue to make the same error without knowledge they are doing something incorrectly inc
81. these institutions are not mandated to report FCDS encourages them to voluntarily report their cancer cases in order to provide complete cancer incidence in Florida AMBULATORY SURGERY CENTERS In July 1997 the Florida legislature amended state cancer reporting legislation to include cancer case reporting by ambulatory patient care facilities The Florida Department of Health and FCDS agreed that in order to ease the burden of reporting by ambulatory centers FCDS would take on the responsibility of cancer case identification the critical first step in the reporting of cancer cases Administrative Options for Reporting for Ambulatory Surgical Centers 1 Facilities with a History of Reporting Several ambulatory surgical centers already voluntarily report complete cancer cases to FCDS Reporting by these facilities will continue as in the past The FCDS notification of cases for cancer reporting for these facilities will actually be a quality control exercise Cases identified through the notification process will be considered Missed Cases and will need to be reported in a timely manner 2 Annual reporting through the FCDS Notification of Cases Annual AHCA Audit The AHCA discharge data from the surgical centers is matched with the complete FCDS Master file database regardless of the type of cancer or the date of discharge Records are matched on Social Security Number Date of Birth Sex Race and County of Residence Each AHCA re
82. ting facility to submit a case to FCDS It specifically 1 calculates the difference between the date the reporting facility had the first contact with the patient and the date the case was abstracted 2 calculates the difference between the date the case was abstracted and the date the case entered the FCDS Master File and 3 calculates the difference between the date the reporting facility first had contact with the patient and the date the case entered the FCDS Master File The time between the date the reporting facility had contact with the patient and the date the case entered the FCDS Master File should be 180 days or less These same data are included in the Quarterly Activity Report see Section Forms Other Quality Control Studies and Audits FCDS Quality Control staff will run quarterly reports to help identify areas of concern regarding reporting by individual facilities These quarterly reports will be used to identify trends in case reporting that may need to be addressed at a facility or at the state level For example if a facility reports that 95 of their prostate cases are unstaged at the time of first contact with their facility there may be a problem with the abstractor s understanding how to correctly interpret the field FCDS Stage at First Contact and or how to code it correctly Similar analyses will be conducted for individual abstractors within the facility The FCDS Quality Control staff will perform ad hoc inqu
83. wide patient encounter files AHCA Casefinding Audits AHCA Match iv Annual Linkage to Florida s Bureau of Vital Statistics statewide death files Mortality Casefinding Audits Death Certificate Notifications b Accuracy is the extent to which the data submitted have been correctly coded and match the information contained in the medical record Accuracy encompasses correct interpretation and application of coding rules and guidelines identifies data entry and data submission errors and evaluates case correctness Accuracy is assessed using i FCDS Abstractor Code Testing ii FCDS Abstractor Code Annual Renewal Testing ill Field Item Inter Item and Intra Item Data Edits iv QC Visual Review Sampling of Every 25 Record v On Site Re Abstracting Audits vi Remote Access Re Abstracting Audits vil Mail In Re Abstracting Audits viii FCDS Management Reports c Timeliness involves how quickly each reporting facility submits cases to FCDS once a patient enters the health care system The standard set forth by NAACCR CDC NPCR ACOS COC and FCDS is 95 of all new reportable cancer cases seen at any facility must be abstracted submitted and any corrections for edit failures be completed within 6 months from the date of Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 29 service 100 of cases must be submitted by June 30 of any given year Timeliness is assessed using i Admissions by Facility Report ii
84. will not begin work on the project until we have received all of the necessary approval and paperwork directly from the DOH Bureau of Epidemiology Only those data items variables specified in the Application for Research Use of the Florida Cancer Data System will be extracted FCDS will fill confidential data requests within 6 weeks time once the request and cost have been approved Please note that approval for confidential data through Florida Department of Health can take anywhere from 8 weeks to 18 months depending on complexity and thoroughness of the request of the application Please plan accordingly 4 Data Linkage A data linkage project is a request that involves linking FCDS data to external or internal data sets The preliminary steps involving linkages are identical to those of confidential data requests Please Revised 2014 SECTION I GUIDELINES FOR CANCER DATA REPORTING 38 refer to the confidential data requests section above Fields used in the linkage must be consistent in both data sets The researcher should send FCDS the data in a fixed length ASCII file with the proper record layout and format Refer to Data Linkage Record Layout document Any deviations from the record layout or format will require extra work and will be charged to the requestor according to the fee schedule Refer to Fees and Billing Procedure below FCDS will fill data linkage requests within 6 weeks following approval of the request an
85. ymphoid Neoplasm Case Neoplasm Case Reportability and Coding and Lymphoid Reportability and Coding Reportability and Coding Manual and the 2014 Manual and the 2014 Manual and the 2014 Hematopoietic Database Neoplasm Rules Hematopoietic Database Hematopoietic Database apparent ly apparent ly apparent ly appears appears appears comparable with compatible with consistent with favors malignant appearing comparable with compatible with consistent with favors malignant appearing comparable with compatible with consistent with favors malignant appearing Ambiguous most likely most likely most likely presumed presumed presumed Terminology probable probable probable Considered as suspect ed suspect ed suspect ed suspicious for suspicious for suspicious for Diagnostic of typical of typical of typical of Cancer Exception if the cytology is Exception if the cytology is Exception if the cytology is reported as reported as suspicious and reported as suspicious and suspicious and neither a positive biopsy neither a positive biopsy nor neither a positive biopsy nora nor a physician s clinical impression a physician s clinical physician s clinical supports the cytology findings do not impression supports the impression supports the consider as diagnosis of cancer cytology findings do not cytology findings do not consider as diagnosis of consider as diagnosis of cancer cancer Ambiguous

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