Changes to the Collection of AJCC Fields

AJCC and NCDB Announce New AJCC T, N, and M Categories implemented in 2016 for cases diagnosed 1/1/16 forward.  This includes a “c” clinical and “p” pathologic designation available in the registry software so registrars can comply with the AJCC staging rules. This will take effect for the NAACCR 16 compliant software upgrades for registry software.   More information will be coming in the future as we…

Posted on Jun. 24, 2016 in How Should I Code This?

Appropriate Antibiotic Administration VS. Antibiotic Administration

When abstracting this element, there are two parts – 1) did the patient have IV antibiotics administered? (Was a broad spectrum or other antibiotic administered intravenously in the time window 24 hours prior to or 3 hours following the presentation of severe sepsis?) AND 2) were the appropriate antibiotics administered? (Was the intravenous (IV) antibiotic administered within 3 hours after the date and time of presentation…

Posted on Jun. 3, 2016 in How Should I Code This?

How Should I Code This? – SURGICAL MARGINS OF PRIMARY SITE

Coding surgical margins is sometimes challenging.  Below are some tips to assist in coding this field. Record the margin status as it appears in the pathology report Code 7 if the pathology report indicates the margins could not be determined Code 9 if the pathology report makes no mention of margins or no tissue was sent to pathology. Code 1 if involvement is indicated but not…

Posted on May. 27, 2016 in How Should I Code This?

Collaborative Staging Questions Part 2

Q:     Patient was recently diagnosed with multiple myeloma being treated with chemo elsewhere.  He reports to the reporting facility with fever, chills and malaise.  He is admitted for two days for IV antibiotics and observation.  Is this class 31 (in-transit care) or 32 (active disease)? A:     This is a class 32 (active disease).  Only record as class 31 if pt. receives in-transit cancer directed treatment.  Please…

Posted on Nov. 2, 2015 in How Should I Code This?