SSDI and Grade Lookup

Notes

1. Grade Clinical must not be blank.

   • Grade Clinical must not be blank.

2. Assign the highest grade from the primary tumor assessed during the clinical time frame.

   • Assign the highest grade from the primary tumor assessed during the clinical time frame.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Priority order for codes

   • Urothelial cancers (WHO/ISUP grade): use codes L, H and 9
   • - If only G1-G3 are documented, code 9
   • Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9
   • - If only L or H are documented, code 9

5. G3 includes undifferentiated and anaplastic.

   • G3 includes undifferentiated and anaplastic.

6. For bladder, a TURB qualifies for a clinical grade only.

   • For bladder, a TURB qualifies for a clinical grade only.

7. Code 9 (unknown) when

   • Grade from primary site is not documented
   • Clinical workup is not done (for example, cancer is an incidental finding during surgery for another condition)
   • Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

8. If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a Grade Clinical and code appropriately per Grade Clinical categories for that site, and then code unknown (9) for Grade Pathological, and blank for Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp).

   • If there is only one grade available and it cannot be determined if it is clinical or pathological, assume it is a Grade Clinical and code appropriately per Grade Clinical categories for that site, and then code unknown (9) for Grade Pathological, and blank for Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp).

Code Table

Notes

1. Grade Pathological must not be blank.

   • Grade Pathological must not be blank.

2. There is a preferred grading system for this schema. If the clinical grade given uses the preferred grading system and the pathological grade does not use the preferred grading system, do not record the Grade Clinical in the Grade Pathological field.

   • *Example:* Biopsy reports states moderately differentiated adenocarcinoma. The surgical resection states a high grade adenocarcinoma. Assign Grade Pathological 9
   • - Code Grade Clinical as 2 since Moderately differentiated (G2) is the preferred grading system
   • - Code Grade Pathological as 9 (unknown) per **Note 5**. Code H would not be used since the histology was not an urothelial histology

3. Assign the highest grade from the primary tumor.

   • Assign the highest grade from the primary tumor.

4. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

5. Priority order for codes

   • - Urothelial cancers (WHO/ISUP grade): use codes L, H and 9
   • + If only G1-G3 are documented, code 9
   • - Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9
   • + If only L or H are documented, code 9

6. G3 includes undifferentiated and anaplastic.

   • G3 includes undifferentiated and anaplastic.

7. For bladder, a TURB does not qualify for surgical resection. A cystectomy, or partial cystectomy, must be performed

   • For bladder, a TURB does not qualify for surgical resection. A cystectomy, or partial cystectomy, must be performed

8. Use the grade from the **clinical work up** from the primary tumor in different scenarios based on behavior or surgical resection

   • **Behavior**
   • - Tumor behavior for the clinical and the pathological diagnoses are the same AND the clinical grade is the highest grade
   • - Tumor behavior for clinical diagnosis is invasive, and the tumor behavior for the pathological diagnosis is in situ
   • **Surgical Resection**
   • - Surgical resection is done of the primary tumor and there is no grade documented from the surgical resection
   • - Surgical resection is done of the primary tumor and there is no residual cancer
   • **No surgical resection**
   • - Surgical resection of the primary tumor has not been done, but there is positive microscopic confirmation of distant metastases during the clinical time frame

9. Code 9 (unknown) when

   • Grade from primary site is not documented
   • No resection of the primary site (see exception in **Note 8**, Surgical resection, last bullet)
   • Neo-adjuvant therapy is followed by a resection (see Grade Post Therapy Path (yp))
   • Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available
   • Clinical case only (see Grade Clinical)
   • There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

Code Table

Notes

1. Leave Grade Post Therapy Clin (yc) blank when

   • No neoadjuvant therapy
   • Clinical or pathological case only
   • Neoadjuvant therapy completed, no microscopic exam is done prior to surgery/resection of primary tumor
   • There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

2. Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.

   • Assign the highest grade from the microscopically sampled specimen of the primary site following neoadjuvant therapy or primary systemic/radiation therapy.

3. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

4. Priority order for codes

   • - Urothelial cancers (WHO/ISUP grade): use codes L, H and 9
   • + If only G1-G3 are documented, code 9
   • - Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9
   • + If only L or H are documented, code 9

5. G3 includes undifferentiated and anaplastic.

   • G3 includes undifferentiated and anaplastic.

6. For bladder, a TURB qualifies for a clinical grade only.

   • For bladder, a TURB qualifies for a clinical grade only.

7. Code 9 (unknown) when

   • Microscopic exam is done after neoadjuvant therapy and grade from the primary site is not documented
   • Microscopic exam is done after neoadjuvant therapy and there is no residual cancer
   • Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available

Code Table

Notes

1. Leave Grade Post Therapy Path (yp) blank when

   • No neoadjuvant therapy
   • Clinical or pathological case only
   • Neoadjuvant therapy completed; surgical resection not done
   • There is only one grade available and it cannot be determined if it is clinical, pathological, post therapy clinical or post therapy pathological

2. There is a preferred grading system for this schema. If the post therapy clinical grade given uses the preferred grading system and the post therapy pathological grade does not use the preferred grading system, do not record the Grade Post Therapy Clin (yc) in the Grade Post Therapy Path (yp) field.

   • *Example:* Neoadjuvant therapy completed. Biopsy reports states moderately differentiated adenocarcinoma. The surgical resection states a high grade adenocarcinoma. Assign Grade Post Therapy Path (yp) 9
   • Code Grade Post Therapy Clin (yc) as 2 since Moderately differentiated (G2) is the preferred grading system
   • Code Grade Post Therapy Path (yp) as 9 (unknown) per **Note 5**. Code H would not be used since the histology was not an urothelial histology

3. Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

   • Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.

4. If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

   • If there are multiple tumors with different grades abstracted as one primary, code the highest grade.

5. Priority order for codes

   • - Urothelial cancers (WHO/ISUP grade): use codes L, H and 9
   • + If only G1-G3 are documented, code 9
   • - Adenocarcinomas and Squamous Cell Carcinomas: use codes 1-3, 9
   • + If only L or H are documented, code 9

6. G3 includes undifferentiated and anaplastic.

   • G3 includes undifferentiated and anaplastic.

7. For bladder, a TURB does not qualify for surgical resection. A cystectomy, or partial cystectomy, must be performed

   • For bladder, a TURB does not qualify for surgical resection. A cystectomy, or partial cystectomy, must be performed

8. Use the grade from the post therapy **clinical work up** from the primary tumor in different scenarios based on behavior or surgical resection

   • **Behavior**
   • Tumor behavior for the post therapy clinical and the post therapy pathological diagnoses are the same AND the post therapy clinical grade is the highest grade
   • Tumor behavior for post therapy clinical diagnosis is invasive, and the tumor behavior for the post therapy pathological diagnosis is in situ
   • **Surgical Resection**
   • Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no grade documented from the surgical resection
   • Surgical resection is done of the primary tumor after neoadjuvant therapy is completed and there is no residual cancer

9. Code 9 (unknown) when

   • Surgical resection is done after neoadjuvant therapy and grade from the primary site is not documented and there is no grade from the post therapy clinical work up
   • Surgical resection is done after neoadjuvant therapy and there is no residual cancer and there is no grade from the post therapy clinical work up
   • Grade checked "not applicable" on CAP Protocol (if available) and no other grade information is available

Code Table