Casefinding

• Admission and discharge documents
• Autopsy reports
• Disease indexes
• Outpatient’s medical records/logs
• Surgery schedules/logs
• Nuclear medicine documents
• Pathology and Cytology reports
• Radiation oncology logs
• Hematology reports
• Medical oncology logs
• Diagnostic imaging
• Neurology clinics

Casefinding in medical records/health information should be done using both inpatient and outpatient disease/diagnostic indexes. Review all records with the following ICD-10-CM codes.

Reproduceable current year and past years’ case finding lists can be found here:

ICD-10-CM Casefinding List, 2024
Based on the International Classification of Diseases, ICD-10-CM Tabular List of Diseases and Injuries, FY 2024

• Health Information Management Department (HIM)/Medical Records Dept. This department maintains the medical records and a disease index that identifies the patient, date of service, and the diagnosis. See SEER Casefinding Lists ICD-10-CM codes and procedures for casefinding by Disease Index.
• Pathology and Cytology Departments. The histology, cytology, bone marrow, and autopsy reports are source documents for identifying eligible cases.
• Oncology-related services. Radiation and medical oncology treatment areas are sources of casefinding. All in-patient and outpatient services should be checked.
• Staff physician’s office. The physician’s office is a source of casefinding.

The Notifiable Disease Law, Official Code of Georgia (OCGA) Annotated 31-12-2 ., mandates the reporting of certain diseases including cancer. All CANCERS diagnosed since January 1, 1995, in persons receiving cancer diagnostic and/or management services or who have active disease MUST be reported to the Georgia Cancer Registry (GCR), unless previously reported by that facility.

All health care providers in the state of Georgia are required to report specific information on cancer in their patient population to the Georgia Cancer Registry. This includes all facilities providing diagnostic evaluations and/or treatment for cancer patients, such as: hospitals, outpatient surgical facilities, laboratories, radiation therapy and medical oncology facilities, physicians, and physicians’ offices.

Cases to Report

The Georgia Cancer Registry Requires the Following Cases to Be Reported:

All neoplasms diagnosed or treated in a hospital with a behavior code of “2” or “3”, as specified in the International Classification of Diseases for Oncology, appropriate edition according to the year of diagnosis, regardless of class of case. Refer to the Reportability Section as well as Appendix E of the corresponding year SEER Program Coding and Staging Manual for exceptions.

As of January 1, 2004, any case diagnosed with benign brain and central nervous system tumors are reportable.

Patients with active disease while an inpatient or outpatient at a facility, regardless of reason for admission or service. Also, patients who had cancer diagnostic and/or management services given or planned while at the facility even without active disease.

Patients whose diagnoses are not histologically confirmed (clinical diagnoses). Georgia and non-Georgia residents.

Types Of Cases to Include

For specific codes and explanation see Class of Case.pdf .

Inpatient and Outpatient:

All inpatient and outpatient cases must be included in the casefinding process. This includes outpatient departments located within the facility and those physically located outside the facility.

IF the facility owns the medical record. An example of this would be if a hospital owns a freestanding outpatient surgical center. The cases from this center would be identified and reported.

All Class of Cases (Analytic and Non-Analytic)

All accessioned cases are assigned a Class of Case (NAACCR Item #610) based on the nature of involvement of the facility in the care of the patient.

Class of Case 00-22: Cases diagnosed and/or administered any of the first course of treatment at the accessioning facility after the registry’s reference date are analytic. A network clinic or outpatient center belonging to the facility is part of the facility. Class of Case 10-22 are included in treatment and survival analysis. If the patient receives no treatment, either because the patient refuses recommended treatment or a decision is made not to treat, the Class of Case is 14. If there is no information about whether or where the patient was treated, the Class of Case is 10.

Nonanalytic Cases

Class of Case 30-99 are not usually included in routine treatment or survival statistics. The CoC does not require registries in accredited programs to accession, abstract, or follow these cases, but the GCR requires them. GCR does not collect “history only” cases (class of case 33). Do not submit these cases to GCR.

Modifications to Class of Case in 2010

Class of Case was redefined for use beginning in 2010. The codes in this manual allow differentiation between analytic and nonanalytic cases and make additional distinctions.

For analytic cases, the codes distinguish cases diagnosed in a staff physician’s office from those diagnosed initially by the facility and patients fully treated at the facility from those partially treated by the reporting facility. Nonanalytic cases are distinguished by whether the patient received care at the facility or did not personally appear there.

Patients who received care from the facility are distinguished by the reasons a case may not be analytic: diagnosed prior to the patient’s reference date, type of cancer that is not required by CoC to be abstracted, consultation, in-transit care, and care for recurrent or persistent disease. Patients who did not receive care from the reporting facility are distinguished by care given in one or more staff physician offices, care given through an agency whose cancer cases are abstracted by the reporting facility but are not part of it, pathology only cases, and death certificate only cases. Treatment in staff physician offices is now coded “treated elsewhere” because the hospital has no more responsibility over this treatment than it would if the patient were treated in another hospital.

Clinical diagnoses:

It is important to remember that all clinical diagnoses are also reportable. Histologic confirmation is not required for these cases. The clarification regarding ambiguous terminology (Refer to Ambiguous Terminology in the Reportability Section of the corresponding year SEER Program Coding and Staging Manual) may be helpful in determining if a case with an unclear diagnosis is reportable. NOTE: Radiology only cases (x-rays and scans) must be reported if diagnostic of cancer, including those with reportable ambiguous terminology; however, Lab only cases are not required to be reported (for example PSA reports).

Tissue Only cases (pathology):

This is sometimes referred to as “tissue, no body” and occurs when a facility’s pathology department processes and interprets specimens that were collected from outside sources, such as another hospital or from a physician’s office. If the facility receives a pathology specimen diagnostic of cancer from another hospital, the facility is NOT required to report the case. The facility that receives a pathology specimen diagnostic of cancer from a physician’s office must report that case. It is the responsibility of the reporting facility that first collected or received the specimen to report the case. Just remember to follow two basic guidelines:

If the specimen originates (or is collected) from a physician’s office, report the case.

If the specimen is from another hospital, do not report the case.

Remember:

ALL items in the GCR Required Data Set must be completed if reporting electronically or included if submitting photocopies of medical records.

Data needed by GCR includes all information from the date of initial diagnosis (OR FIRST VISIT TO YOUR FACILITY) through completion of first course treatment.

If you discover a case that was previously diagnosed, you should go back and submit the first admission to your facility indicating the presence of cancer. The earliest information available regarding a patient’s cancer is needed. Of course, if you had previously submitted that case, you would not need to submit it again. For example, you are conducting your casefinding for June 2024 and you have a patient on your disease index with a diagnosis of colon cancer. The H & P states that the patient is being admitted for a bowel obstruction, possibly a recurrence. First determine the patient does not have a new primary using the Solid Tumor Rules. If not a new primary, and in reviewing the record you see that the patient was admitted to your facility in October 2022 for colon cancer, but not reported at that time, you would need to go back and update your abstract to include the October 2022 admission as date of first contact. This would be sent as an update to GCR in your monthly Modified Record submission.

Death clearance is conducted every year by GCR to improve completeness of reporting. The first step matches Death Certificates that list a reportable cancer as a cause of death against the data base of reported cancers. This initial step produces three outcomes: positive matches, possible matches and non- matches. The non-matches create a follow-back list which is distributed to the institution mentioned on the death certificate or hospital discharge file. The facility is to find information about the specific cancer diagnosis listed on their follow-back list. Hospitals are expected to send the follow-back data to GCR within 60 days from the date they receive the list.

How to Submit:

• Upload to Labkey
• Labkey Instructions
• Contact your Regional Coordinator if assistance is needed.

Rapid Case Ascertainment (RCA) is a case finding procedure to identify newly diagnosed reportable cancer cases as rapidly as possible following diagnosis. Information obtained through RCA will serve as one method to assess case completeness, will provide an additional source of quality control for incoming data, and will permit cancer incidence in Georgia to be reported earlier than would otherwise be possible. The RCA system can also assist researchers in identifying cases that may be eligible to participate in research studies approved by the Georgia Department of Public Health, Institutional Review Board (DPH/IRB) see Confidentiality.

The Georgia Cancer Registry (GCR) implemented a statewide policy for RCA requiring the monthly submission of pathology reports related to reportable cancers from all facilities in Georgia beginning January 1, 2011. The adoption of electronic pathology reporting for all electronic reporting facilities is paramount to the timely, efficient collection and integration of these critical data into the GCR. Electronic data can be more effectively imported into existing cancer data management systems while paper reports still require a substantial amount of manual effort related to data integration. To move this important effort forward, the GCR is mandating the electronic submission of pathology reports from all electronic reporting facilities/labs in Georgia and from all other non-electronic facilities as available, effective in 2017.

The procedures below outline the options currently available for RCA. Option A is the only option available to electronic reporting facilities as electronic reporting is now mandatory.

Rapid Case Ascertainment Options

1. Epath, an electronic pathology reporting system, is the preferred and most efficient method to meet the requirement for timely pathology reporting. Epath is an application that can be installed on an existing machine (or virtual machine) in the pathology laboratory. Pathology reports are filtered by the Epath system to identify and send only reportable cancer reports. The security infrastructure of Epath is compliant with HIPAA requirements. Reports are encrypted and electronically transmitted in real time to a dedicated computer at the GCR. For hospital pathology laboratories, the same reports are simultaneously sent to the hospital tumor registry facilitating efficient and timely registry pathology case finding. Electronic reporting facilities that cannot, or elect not to report through Epath, must report their pathology through another electronic (machine readable) format. Please contact your Regional Coordinator for other electronic options.
2. Non-electronic pathology facilities should utilize the preferred Labkey System on the GCCS website to upload pathology reports and accompanying patient demographics. The reports can also be uploaded to a secure sFTP site provided by the GCR. Please contact the GCR at gccs@sph.emory.edu if you would like to establish a sFTP site for your facility.
3. Non-electronic facilities without a pathology laboratory are to send an electronic (i.e., excel, csv) disease index file at the end of each month, or as instructed by your Regional Coordinator, to the GCR using the Labkey System on the GCCS website. GaDirect webdirect account or sFTP accounts are available while users are transitioning to the Labkey System. A receipt confirmation is sent by email to the facilities.

• Apparent(ly)
• Appears
• Comparable with
• Compatible with
• Consistent with
• Favor(s)
• Malignant appearing
• Most likely
• Presumed
• Probable
• Suspect(ed)
• Suspicious (for)
• Typical (of)

Refer to the SEER Program Coding and Staging Manual 2024

Reportable Diagnoses

1. Generate a list using appropriate ICD-10-CM Codes.
2. Delete any codes that are not reportable (Facility IT should be able to exclude non-reportable codes when producing this list).
3. Submit only cases that meet the criteria for Reportability as identified in the corresponding year SEER Program Coding and Staging Manual. .

Things to Consider

• Know the codes (specific to your facility). Do your disease index codes reflect codes for procedures, symptoms, provisional diagnosis, diagnosis as stated on order from doctor, or final diagnosis? (You need to use the final diagnosis code for Casefinding.)
• Are all points of service included on the disease index?
• How are x-rays and scans coded? Is there a way to obtain abnormal reports to review?
• V-Codes – no need to include these. If diagnosis is being coded correctly and they have active disease, code will reflect the “cancer code”.
• The is a SCREENING TOOL ONLY.

1. Visually review ALL path reports if there is no automated screening mechanism currently in place.
2. Check for missing numbers in sequential accession numbers
3. Note the clinical diagnosis if listed on the path report (patient may have a negative path that was treatment for a cancer)

The suspense file documents and organizes casefinding and is an essential component of reporting. This file is used to store or keep a record of the cases which have been determined to be reportable. The cases are kept in this file until they are actually abstracted or submitted.

Some registries use copies of pathology reports, which are checked against the patient index and then sorted alphabetically by month. In addition to the pathology report, a listing of cases identified from other sources/departments is maintained. The hospital’s diagnostic indices by month may also be placed in the pending file.

A computer program can serve as your pending file. In this case, preliminary data is entered into the program and once the case is completed, by adding all required data to the file, it would then be converted to a primary site file (abstract).

Your pending file is also helpful in preventing duplication. When a new case is identified, you should check it against your patient index file (master file) and against your pending file to make sure the case hasn’t already been identified. Another method that is helpful in preventing duplication is to “flag” the medical record charts of the submitted cases It is important to use the Solid Tumor Rules and the Hematopoietic and Lymphoid Neoplasm Coding Manual to determine if a cancer is a duplicate or a new primary. Your Regional Coordinator can assist you in determining multiple primaries.