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April 2014

Are Cancer Registrars Ready for ICD-10?
By David Yeager
For The Record
Vol. 26 No. 4 P. 16

One-year reprieve or not, these professionals may be a step ahead of their coding counterparts.

On October 1, 2015, the code sets used to report medical diagnoses and inpatient procedures will switch from ICD-9-CM to ICD-10-CM. Despite the recent edict to extend the implementation deadline by at least one year, HIM professionals remain poised for a new reality. While the change will be a big shift for medical coders, the new coding system also will affect how cancer registrars go about their jobs.

To prepare for ICD-10-CM, Jennifer Ruhl, MSHCA, CCS, RHIT, CTR, a public health analyst and certified tumor registrar in the quality control section of the Surveillance, Epidemiology, and End Results (SEER) program at the National Cancer Institute, has some advice for cancer registrars: Don’t panic.

Part of the reason to remain calm—besides the recent announcement of at least a one-year delay—is that cancer registrars need to know only a portion of ICD-10-CM. Ruhl says the majority of ICD-10-CM codes that registrars will need to become familiar with are located between sections C00 and C96. Sections D00 to D49 also are important.

Since registrars already use ICD-10 for certain functions, this also should help lessen any stress related to the transition. For example, the ICD-O-3 codes used for histology and cancer site coding are based on ICD-10 codes, giving registrars a leg up on their coding colleagues. “Actually, it’s going to make things a lot easier for cancer registrars because we’re already used to seeing the majority of the cancer codes from ICD-10,” Ruhl says.

Adjustment, Not Overhaul
But that doesn’t mean there won’t be any changes. When registrars compile casefinding lists, which identify the cases that belong in the registry database, they often run reports, such as those drawn from a hospital’s disease index database, based on ICD-9-CM codes. ICD-9–based reports also are generated from admission/discharge/transfer data, a common source for cancer registrars who must adjust accordingly.

“As the hospitals implement ICD-10, cancer registrars will have to refine some of their processes to include ICD-10 codes in their casefinding processes, just to be able to query,” says Laurie Hebert, RHIA, CCS, CCS-P, CTR, a member of the National Cancer Registrars Association (NCRA) and the vice president and general manager of cancer registry services at Care Communications, a provider of HIM solutions.

To help with the change, SEER’s website provides conversion files for easy reference. According to Ruhl, in some cases, the conversion files have been around for years. For example, registrars have been using ICD-10 codes to report cause of death since 1999. In anticipation of the industrywide change, more conversion files have been added, with six available at press time.

Ruhl says the Centers for Medicare & Medicaid Services’ general equivalence mappings (GEMs) also are a useful resource. GEMs list the most appropriate ICD-10-CM codes for a given item but, because ICD-10-CM is much more specific than ICD-9-CM, there may be five codes instead of one. Cancer registrars will have to figure out the appropriate code.

Procedure codes are another area where cancer registrars will face an adjustment, says Ruhl, who has spoken to several who are finding the conversion process to be difficult. Part of the problem is that a particular surgery or medical procedure can be used to treat various medical conditions, either cancerous or benign, and determining whether a procedure was used for cancer treatment is an inexact science. As a result of the confusion, Ruhl is planning to develop a conversion file to address any discrepancies.

“One of the challenges we do have, which we have not addressed yet, is to look at procedure coding,” Ruhl says. “There was a big change for diagnosis coding, going from ICD-9-CM to ICD-10-CM. However, I think the procedure coding changes will be much more dramatic. The biggest challenge for registries that use procedure coding to help them identify cancer-directed treatment is going to be determining which codes we need to look for.”

Ruhl says guidance on surgery codes also will be key to a smooth transition. Matters are complicated by the fact that the definitions of these codes differ between cancer registrars and coders. In addition, she says the terms are a bit outdated. Unfortunately, it’s not yet clear how ICD-10-CM will be applied to surgery codes; some conversions will be one-to-one matches, but many will not. Many of the conversions will have to be reviewed for accuracy.

Another challenge will be disease codes. (Hospitals that maintain Commission on Cancer accreditation or collect data for the American Joint Committee on Cancer include disease codes in their registries.) These cases can become complicated when patients with cancer have other diseases as well. Registrars don’t code for these comorbid conditions, but they do copy the disease codes into the registry’s database, making it necessary for them recognize these codes.

“The No. 1 source that we use to find our cases is pathology reports. The second one is the disease index. If the coding of the ICD-10 is correct, then it will be very helpful for us in finding the cases that we need to record,” says Elizabeth R. Patena, MD, CTR, vice president of cancer registry for Medical Record Associates, a provider of HIM services. “One good thing about ICD-10 is that it has more specificity. Now, for example, there’s added coding for whether it is a right breast or a left breast, which is important because, when we do casefinding, we also try to determine whether it’s a new breast case or a recurrence of the previously reported case.”

Many state registries also collect disease data to compare with the information contained in their database. Ruhl, who has received only a few questions from states about disease lists, says the state registries are basically using SEER’s casefinding application to convert the codes from ICD-9-CM to ICD-10-CM.

Because state registries operate on the same principles as hospitals, they should be fairly well prepared, according to Karen Phillips, BS, CTR, a decision support product manager at Elekta, a provider of cancer care clinical solutions and data management. “State registries are already using ICD-10 for many functions,” she notes. “They will continue to use ICD-10 for case matching, record and tumor linkage, death coding and, to some extent, for special studies.”

Ready, Set…
Because ICD-10-CM is being implemented at the beginning of the government’s fiscal year rather than the beginning of the calendar year, it has caused some confusion for cancer registrars, whose diagnosis year begins on January 1. Casefinding lists usually are completed at the beginning of the year, with any October 1 updates incorporated as necessary. Ruhl says many in the cancer registry community aren’t aware of this discrepancy. However, the one-year delay allows for more time to spread the word.

The postponement also helps allay fears about potential damage from a large update in 2015 or 2016 that will make the casefinding process more challenging over the next two to three years. Ruhl says the size of the updates will determine the length of the adjustment period.

Next year, registrars performing casefinding will need to use ICD-9-CM and ICD-10-CM while some hospitals will be coding both sets concurrently. Following the switch to ICD-10-CM, there will be some catch-up work for patients who were seen before October 1, 2015. If cancer registrars encounter both sets of codes, they’re supposed to copy both sets, says Ruhl, who expects that registrars will see both ICD-9-CM and ICD-10-CM for a while. The good news is that every patient seen after October 1, 2015, will be coded exclusively with ICD-10-CM.

Over time, registrars will see less of ICD-9-CM. However, pre–ICD-10-CM data will not be translated to ICD-10, meaning studies of historical data, such as trends over time, will have to be compiled using both sets of codes.

SEER has worked with the North American Association of Central Cancer Registries (NAACCR) to develop a coordinated approach to the change. Standard-setting organizations, such as SEER, the NAACCR, the NCRA, and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, have provided training and information as well. Still, Ruhl has fielded calls from all over the country from cancer registrars seeking details on what they need to know.

Although it’s relatively easy for medical coders to get the AHIMA-mandated credit hours for ICD-10-CM, cancer registrars may not have kept pace. Cancer registrars who also maintain AHIMA credentials need six continuing education hours of ICD-10-CM training to maintain them. Currently, there is no requirement for ICD-10-PCS training.

Cancer registrars who don’t maintain AHIMA credentials don’t need ICD-10–specific credit hours, but it is strongly recommended that they familiarize themselves with the code set. Unfortunately, medical coder classes likely are more in-depth than what’s necessary for registrars.

“The problem for a cancer registrar who isn’t necessarily interested in keeping up with coding and is strictly interested in cancer registries is that, if you go to a meeting that’s geared toward medical coders, they’re going to go far deeper than the registrar needs to go,” Ruhl says. “That’s one of the things that cancer registrars are running into: They don’t want too much detail.”

With that in mind, SEER has developed presentations to provide four of the six required hours. Ruhl, who has been a driving force behind the educational initiative, says that while the material is highly detailed, it’s geared specifically to cancer registrars and can be used by hospitals, state registries, or contractors. The registrar community has responded positively to the program, adds Ruhl, who encourages post–ICD-10 implementation feedback from those who complete the training.

Although the learning curve for medical coders may be steep, cancer registrars likely will have an easier time. In fact, Phillips, who supports the move to ICD-10-CM, believes registrars would have liked to make the switch sooner and are disappointed that its implementation has been delayed for at least another year. “Registrars will welcome this change,” she says. “Moving from the five-digit codes in ICD-9 to the seven-character alphanumeric codes in ICD-10 will allow registrars to be much more specific. For example, sex is included for some sites, and laterality is included for paired sites, like breast, lung, and kidney. There is also updated terminology for blood and lymph cancers. I think this is going to make abstracting easier, not more difficult, and it’s likely to improve overall data accuracy.”

Because of their expertise with cancer codes, registrars are in position to help hospitals make the conversion. Ruhl says some IT professionals are asking registrars questions about which codes are needed to update hospital software systems. Once programs are updated, querying for casefinding should become easier.

Aside from helping IT departments, registrars also can provide guidance to coders, Ruhl says, pointing out that registrars’ ICD-10 background is derived from ICD-O-3 and other sources. Because of that experience, they have gained valuable insight on how cancer codes translate to ICD-10-CM.

Going Forward
Ultimately, however, no one knows exactly how the ICD-10-CM conversion will play out—if ever—but the general consensus is there will be an adjustment period for a wide range of health care professionals. Cancer registrars seem well positioned to play an important role in helping organizations weather any bumps in the road.

Nevertheless, Hebert says registrars may be at the mercy of others. For example, an organization’s ability to make the transition will have a significant effect on cancer documentation. “If the conversions for the hospitals go well, we’re going to be able to go about our work,” she says. “If the hospitals have difficulty with the transition, then it will backlog our work because we won’t be able to get access to the records.”

In the meantime, for registrars unsure about what they need to know, help is available. “Utilize what’s on the SEER website. The information that is available there is invaluable,” Hebert says. “A lot of work has gone into putting together those tools.”

— David Yeager is a freelance writer and editor based in Royersford, Pennsylvania.


• Centers for Disease Control and Prevention National Program of Cancer Registries (www.cdc.gov/cancer/npcr)

• Centers for Medicare & Medicaid Services 2014 ICD-10-CM and GEMs (www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html)

• National Cancer Registrars Association (www.ncra-usa.org/i4a/pages/index.cfm?pageID=1)

• North American Association of Central Cancer Registries (www.naaccr.org)

• Surveillance, Epidemiology, and End Results (SEER) Program Cancer Registrar Training (http://seer.cancer.gov/training)

• SEER Casefinding Lists (http://seer.cancer.gov/tools/casefinding)

• SEER Training Modules — Casefinding (http://training.seer.cancer.gov/casefinding)