Grade Coding Manual

Version and Publication

• Grade Coding Instructions and Tables is effective for cases diagnosed 1/1/2018 and forward.
• It was published in September 2024
• The document is version 3.2.

Editors

• The editors are Jennifer Ruhl and Jim Hofferkamp.
• Jennifer Ruhl's credentials include: MSHCA, RHIT, CCS, CTR, NCI SEER
• Jim Hofferkamp's credentials include: CTR, NAACCR

Suggested Citation

• The suggested citation style is: Ruhl J, Hofferkamp J, et al. (September 2024). Grade Manual. NAACCR, Springfield, IL 62704-4194

Funding Details

• Funding came from the National Cancer Institute, National Institutes of Health, and Department of Health & Human Services under contracts HHSN261201400004I / HHSN26100002.
• Additional funding came from the Centers for Disease Control and Prevention Cooperative Agreement number 5NU58DP004917.
• The views expressed are solely the responsibility of the authors and do not necessarily represent the official views of the NCI and CDC.
• The NAACCR Board of Directors adopted these standards in February 2018.

Contribution Acknowledgements

• NAACCR expresses gratitude for the work of the 2020-2022 NAACCR Site-Specific Data Item (SSDI) Work Group.
• Gratitude is expressed to Carolyn Callaghan and Tiffany Janes from the SEER*Educate program for their continued contribution to the SSDI Work Group.
• The AJCC Expert Panels are acknowledged for their assistance in clarifying concepts from the AJCC Cancer Staging Manual, Eighth Edition and AJCC Cancer Staging System Version 9.
• The College of American Pathologists (CAP) is acknowledged for its support through a CAP representative on the SSDI Work Group and the CAP Cancer Committee.
• CAP participation aids in harmonizing data elements between AJCC, NAACCR and the CAP Cancer Protocols (CCPs), and electronic Cancer Checklists (eCCs).
• New CAP-consistent language in SSDI value sets and notes eases the coding of current pathology terminology into exact matches with NAACCR value sets.
• Effort is part of improving interoperability between EHR data sets and NAACCR SSDIS.

Individuals Contributing to Document Support and Web Development

• Suzanne Adams, BS, CTR (IMS)
• Daniel Oluwadare, Programmer, AJCC
• Kathy Conklin, MSCS, Manager of IT, AJCC
• Dustin Dennison, M.MIS (Information Technology Administrator, NAACCR)
• Chuck May, BS (IMS)
• Nicola Schussler, BS (IMS)

Grade Coding Instructions Table of Contents Highlights

• Grade Coding Instructions and Tables offers guidance on using the resource effectively
• Includes grade tables in schema ID order and in alphabetical order of schema ID name.
• Provides an introduction to the 2018 changes in grade coding and background on solid tumor grade.
• Details the use of site-specific grade as required and recommended in the current AJCC Cancer Staging System.
• Presents cancer registry coding of recommended grades for solid tumors and cell indicators or grades for hematopoietic and lymphoid neoplasms.
• Includes general grade coding instructions for solid tumors, instructions for time frames, and autopsy grading.
• Covers item-specific data dictionary and coding guidelines, derived summary grade 2018, and coding guidelines for generic grade categories.
• Provides grade information for various codes ranging from Grade 01 to Grade 99, with specific guidelines

Organization and Use of Grade Coding Instructions and Tables

• The Grade Coding Instructions and Tables (Grade Manual) is the primary resource for documentation and coding instructions for Grade for cases diagnosed on or after January 1, 2018.
• Before using the Grade Manual as reference material, review the introductory materials and general instructions.
• The concepts underscore collection of Grade data items, including use of AJCC-recommended grade tables and the introduction of Grade Clinical, Grade Pathological, Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp) data items.
• Grade tables consider both an AJCC-preferred grade system, and the generic grade system are allowable codes, coding guidelines for Grade Clinical, Grade Pathological, Grade Post Therapy Clin (yc) and Grade Post Therapy Path (yp) data items, and coding instructions for generic grade categories.
• Understanding of the material will facilitate accurate coding of the new Grade Data Items.
• Grade Post Therapy Clin (yc) was added in 2021, and Grade Post Therapy Grade was changed to Grade Post Therapy Path (yp).

Introduction to 2018 Changes in Grade Coding

• Grade measures tumor aggressiveness and is a key prognostic indicator for tumors.
• Historically, cancer registries collected grade based on a generic 4-grade classification.
• The 4-grade classification include: Well differentiated, moderately differentiated, poorly differentiated, undifferentiated or anaplastic.
• These same categories were collected for all reportable primary tumors, and two or three grades were converted to the four-grade values.
• The definition of grade has been expanded.
• The classification of grade varies by tumor site and/or histology from 2018.
• The grading system for a cancer type may have two, three, or four grades.
• No longer will all grades be converted to a four-grade system.

Solid Tumor Grade Information

• Tumor grade is determined by microscopic examination.
• Grade is most commonly determined by assessing how closely tumor cells resemble normal cells of the parent tissue, also known as differentiation.
• Well-differentiated tumor cells are similar to normal cells.
• Poorly differentiated and undifferentiated tumor cells appear disorganized and abnormal, therefore bearing little (poorly differentiated) to no resemblance (undifferentiated) to the cells they originated from.
• Similarities/differences may stem from elements such as pattern, cytology, nuclear or nucleolar features.
• Pathologists use three systems to describe differentiation: two-grade, three-grade and four-grade systems.

Site-Specific Grade Relative to the AJCC Cancer Staging System

• Grade is defined in many AJCC Staging Systems and described in AJCC Principles of Cancer Staging.
• Based on the Staging System, the grade system used must be specified
• When no grade system is recommended, generic cancer registry grade categories may be used.
• Registry software displays the grade table based on registrar entries for primary site, histology, and schema discriminator if applicable.
• Recommended AJCC grade is required to assign stage group (Grade Clinical, Grade Pathological, Grade Post Therapy Clin (yc), Grade Post Therapy Path (yp)) for certain tumors.
• Generic cancer registry grade categories or another definition of grade are used if the recommended AJCC grade is undocumented/unavailable and are listed in the site grade table.
• It may be impossible to determine the AJCC stage group if the recommended AJCC grade is unavailable.
• AJCC Staging Systems that require grade to assign stage group: Esophagus and Esophagogastric Junction, Appendix, Bone, Soft Tissue Sarcoma of the Trunk, GIST, Soft Tissue Sarcoma of the Retroperitoneum, Breast, Prostate.

Cancer Registry Coding of Recommended Grades for Solid Tumors:

• Grade will be collected using Grade Clinical, Grade Pathological, and Grade Post Therapy.
• The codes and coding instructions depend on the type of cancer and apply to solid tumors diagnosed from 2018 forward.
• In 2021, Grade Post Therapy was changed to Grade Post Therapy Path (yp) and Grade Post Therapy Clin (yc) was added.
• Revised grade codes are based on the AJCC Cancer Staging System and/or CAP cancer protocols.
• Each AJCC system with a recommended grading system lists categories and definition in its grade section.
• Recommended AJCC grading systems may also apply for histologic types of tumors within relevant organs but are not eligible in current AJCC Cancer Staging System.
• Generic cancer registry grade categories will still be used for all four grade fields, and for AJCC systems lacking a recommended grading system.
• The registrar is to use the recommended grading system if is it is documented, in the instance of of cases not eligible for AJCC -staging within a specific system