Instead, refer to the multiple primaries and histology coding rules each and every time you encounter a case where the new rules are needed. Explaining Blanks and X, Ambiguous Terminology and Support for AJCC Staging Description Explanations and guidance to the registrar on key topics including: Blank vs. X in registry data fields, ambiguous terminology, stage classification to use based … In order to determine if a term constitutes a diagnosis of cancer, the list of ambiguous terminology in the data standards manuals the registry is required to follow is the first place to check. The 2007 rules come complete with their own set of word lists, definitions, equivalent terms, ambiguous terms, and site-specific rules and priorities. Then look up the terms in the ICD-O-3 to determine if the condition is reportable. In reportable cases, the final diagnosis contains clear terms, or the record contains terminology that would be a qualifying diagnostic element. When deciding whether a case is reportable, cancer registrars have three options. Exception: If the cytology is reported as “suspicious” and neither a positive biopsy nor a physician’s clinical impression supports the cytology findings, do not consider as diagnosis of cancer. Considered as Diagnostic of Cancer. Anything that is not on this list should not be used for assigning the histology code.OK, you're thinking, how am I supposed to remember all these changes? cases eligible to be included in a cancer registry database. WASHINGTON STATE CANCER REGISTRY Reportable List DOH 342 Effective January 1, 2019 Washington State Cancer Registry January 2019 1 ... • If the cytology is reported using any of these ambiguous terms and neither a positive biopsy nor a physician's clinical impression supports the cytology findings, do not consider as diagnostic of Cancer registry personnel use medical terminology skills Cancer registry personnel use medical terminology skills, knowledge of health records, and knowledge of national and state reporting requirements to ensure that all eligible cases are reported to the Florida Cancer Data System. The case only may be abstracted if a physician’s clinical impression of cancer supports the cytologic findings, hence why further investigation, including contacting the physician, sometimes is required.Ambiguous terms that are reportable, or used to determine whether a case is reportable, include “consistent with,” “presumed” and “probable.” Ambiguous terms that are not considered diagnostic of cancer include:So, if for example a final diagnosis is “probable,” it is reportable, but when described as “possible” it is not considered reportable.In order to determine if a term constitutes a diagnosis of cancer, the list of ambiguous terminology in the data standards manuals the registry is required to follow is the first place to check. Sarah is credentialed by the AHIMA as an ICD-10-CM/PCS Trainer, a Certified Coding Specialist (CCS) and Certified Physician-based Coding Specialist (CCS-P). Develop generic guidelines for addressing ambiguous terminology on death DCO cases. They are self-contained. • Provide guidance to cancer registrars on key topics – Blank vs. X in registry data fields – Ambiguous terminology – Stage classification to use based on treatment provided – Guidelines from other sources – Information and questions on AJCC staging Then look up the terms in the ICD-O-3 to determine if the condition is reportable. This includes any terminology in the clinical history or elsewhere in the body of the report (for example, if the clinical history stated “lymphoma”).Certain cases need to be investigated further to determine eligibility; this could include cases in which the final diagnosis is negative or contains ambiguous terminology that does not qualify as being diagnostic.When reviewing medical records or source documents, cancer registrars often find ambiguous terminology. Non-reportable cases are those with no diagnostic terms or terminology in the final diagnosis or elsewhere in the report. Ambiguous Terminology. In other cases, some conditions that sound reportable may not be, while others that don’t sound reportable are.For example, “suspicious” is an ambiguous term, so if cytology is reported as being suspicious, it cannot automatically be interpreted as a diagnosis of cancer. First and foremost, the 2007 multiple primary rules replace all previous multiple primary rules—even the ones that you remember as "so-and-so told me in 1988 that this is how you The 2007 rules come complete with their own set of word lists, definitions, equivalent terms, ambiguous terms, and Experienced registrars will have to "unlearn" or forget the previous rules because many things have changed for 2007 cases.Three important changes in the histology coding rules will be implemented for cases diagnosed on and after January 1, 2007.There will be prioritized guidelines to determine whether the terminology of the final diagnosis represents a more specific histology.