Scenario: 2023
- 07-13-2023 Liver, core biopsy: Hepatocellular carcinoma, grade 3. Prominent cirrhosis noted
- 08-16-2023 Seen by oncology & palliative care. Family decided for home hospice
- Labs Below
| TEST | 06-09-2023 | 07-02-2023 | 07-13-2023 | 08-14-2023 | 08-18-2023 |
| AFP | ^214.1 ng/mL | ^277.4 ng/mL | ^301.4 ng/mL | ||
| Bilirubin | 1.8 mg/dL | ^1.3 mg/dL | ^2.2 mg/dL | ^2.5 mg/dL | ^2.8 mg/dL |
| Creatinine | 1.0 mg/dL | ^1.4 mg/dL | 0.90 mg/dL | 0.70 mg/dL | ^1.5 mg/dL |
| INR | 1.1 | 1.0 | 1.1 |
Question: How would you code the SSDI’s?
Answer & Rationale
SSDI Manual
- General Instructions Rules for Recording Laboratory Values
- All laboratory values must be done no earlier than approximately three months before diagnosis
- Only record test results obtained before any cancer-directed treatment is given (neoadjuvant
- therapy or surgical), unless instructions for a specific laboratory test state otherwise
- Record the highest laboratory value if multiple laboratory tests results are available, unless
instructions for a specific laboratory test state otherwise
- Individual Instructions for AFP, Bilirubin, Creatinine, INR also reiterate
- Record the highest lab value of the highest test result documented in the medical record prior to treatment.
Per SSDI manual we can take the highest results from 3 months prior to diagnosis date (7-13-2023- 3 months prior = 04-13-2023) and prior to date of first course treatment (08-16-2023). So only look for values between 04-13-2023 to 08-16-2023.
| Field | Answer | Document in Text to Substantiate |
| Date of Diagnosis | 07/13/2023 | 07-13-2023 (XYX Facility) Liver, core biopsy: Hepatocellular carcinoma, grade 3. Prominent cirrhosis noted |
| Date of First Course Treatment | 08/16/2023 | 08-16-2023 Seen by oncology & palliative care. Family decided for home hospice |
| AFP PreTX Lab Value | 277.4 |
08-14-2023 AFP ^277.4 ng/mL |
| AFP PreTX Interpretation | 1 | |
| Bilirubin PreTX Lab Value | 2.5 |
08-14-2023 Total Bilirubin ^2.5 mg/dL |
| Bilirubin PreTX Unit | 1 | |
| Creatinine PreTX Lab Value | 1.4 |
07-02-2023 Creatinine ^1.4 mg/dL |
| Creatinine PreTX Unit | 1 | |
| INR Prothrombin Time | 1.1 | 06-09-2023 INR 1.1 |
| Fibrosis Score | 1 | 07-13-2023(XYZ Facility) Liver core biopsy: Hepatocellular carcinoma, grade 3. Prominent cirrhosis noted |