04-14-2023 Recording Referrals to Med Onc/Rad Onc
Scenario #1 2023:
• My Facility diagnosed Breast Cancer Patient treated with Lumpectomy at my facility pT1a pN0(s) cM0 Stage 1A Grade 2 Her2 -, ER+, PR+
• My Facility Referred to Medical Oncology & Radiation Oncology for consideration of chemo/hormone/radiation.
• No other information available at the time of abstracting
Question: How will you code Chemo/Hormone/Radiation/Class of Case at the time of original abstracting?
Answer Below:
| Field | Answer | Rationale |
| Chemotherapy | 88 | SEER Program Coding and Staging Manual 2023 “Assign code 88 when the only information available is a. The patient was referred to an oncologist b. Insertion of port-a-cath Note: Review cases coded 88 periodically for later confirmation of chemotherapy.” STORE 2023 “•Code 88 to indicate referral was made to a medical oncologist and the registry must follow to determine whether it was given. If follow-up with the specialist or facility indicates the patient was never there, code 00. • Cases coded 88 must be followed to determine what kind of chemotherapy was administered or why it was not.” |
| Hormone Therapy | 88 | SEER Program Coding and Staging Manual 2023 “Assign code 88 when the only information available is that the patient was referred to an oncologist Note: Review cases coded 88 periodically for later confirmation of hormone therapy” STORE 2023 “• Code 88 to indicate the patient was referred to a medical oncologist and the registry should follow the case for hormone therapy. If follow-up with the specified specialist or facility indicates the patient was never there, code 00. • Cases coded 88 should be followed to determine whether they received hormone therapy or why not.” |
| Reason No Radiation | 8 | SEER Program Coding and Staging Manual 2023 “Assign code 8 a. If it is known that a physician recommended radiation treatment, but no further documentation is available to confirm it was given b. To indicate referral to a radiation oncologist was made and the registry should follow to determine whether radiation was administered c. If follow-up to the specialist or facility determines the patient was never there and no other documentation can be found, assign Code 1 Note: Cases coded 8 should be followed and updated to a more definitive code as appropriate” STORE 2023 “• Code 8 to indicate referral to a radiation oncologist was made and the registry should follow to determine whether radiation was administered. If follow-up to the specialist or facility determines the patient was never there and no other documentation can be found, code 1. • Cases coded 8 should be followed and updated to a more definitive code as appropriate.” |
| Class of Case | 14 | STORE 2023 “Code the Class of Case that most precisely describes the patient’s relationship to the facility 14 Initial diagnosis at the reporting facility AND all first course treatment or a decision not to treat was done at the reporting facility” Omega QA Team Interpretation & Rationale: At the time you abstracted this case, to your knowledge, your facility diagnosed and performed all first course treatment, we can’t just assume treatment was done elsewhere at the time of abstracting. Code only what you know. If you find out later that further treatment was done elsewhere, at that point in time Class of case would be updated to Class of Case 13. |