View source for L4E rule 1-3 (2018)

This article covers '''L4E rule 1''', '''L4E rule 2''', and '''L4E rule 3''' for the 2018 [[L4E]] [[workload]] system. An overview of the L4E rules is found in the [[L4E rules of 2018]]. 

==Context==
*This rule covers most biopsies/curettages.
*Special biopsies (e.g. medical liver, transplant biopsies) are coded differently, see ''[[L4E]]'' article.

==History==
*''Rule 1'' and ''Rule 3'' are unchanged from ''[[Level 4 equivalent of 2014]]''.
*''Rule 2'' was changed to lower the value of prostate core biopsies sets with a large number of cores; compare with ''[[L4E rule 1-3 (2014)]]''.

==Details==
{| class="wikitable sortable"
! Specimen type(s) 
! Weight (L4E)
! Details
! Examples
! Rule
|-
| Complex skin biopsies and non-GI biopsies with countable fragments 
| 1 L4E / 5 tissue fragments (frags), all fractions are rounded down
| 1-5 frags = 1 L4E, 6-10 frags = 2 L4E, 11-15 frags = 3 L4E, 16-20 frags = 4 L4E<br>"complex skin" includes inflammatory skin, malignancies except [[basal cell carcinoma|BCC]] and [[skin squamous cell carcinoma|SCC]], atypical melanocytic lesions, adnexal tumours, lymphoid infiltrates
| inflammatory skin biopsy 3 frags = 1 L4E, adnexal skin tumour 6 frags = 2 L4E
| Rule 1 <ref name=capacp2018/> 
|-
| Simple skin (non-complex skin)
| 0.5 L4E/biopsy (1 L3/biopsy)
| biopsies > 2 cm - use [[L4E rule 4 (2018)|L4E rule 4]]; includes [[basal cell carcinoma|BCC]], SCC, actinic keratosis, intradermal nevus
| punch biopsy of BCC = 0.5 L4E, shave biopsy of [[seborrheic keratosis]] = 0.5 L4E
| Rule 1 <ref name=capacp2018/> 
|-
| Medical GI biopsies 
| 1 L3/3 tissue fragments (frags), all fractions are rounded down; 1 L3 = 0.5 L4E
| 1-3 frags = 0.5 L4E, 4-6 frags = 1 L4E, 7-9 frags = 1.5 L4E, 10-12 frags = 2 L4E, 13-15 frags = 2.5 L4E, 16-18 frags = 3 L4E, 19-21 frags = 3.5 L4E, 22-24 frags = 4 L4E 
| 6 frags colorectal biopsies = 1 L4E 
| Rule 1 <ref name=capacp2018/> 
|-
| Surgical GI biopsies (neoplastic/pre-neoplastic) 
| 1 L3/lesion (if submitted in one block) and low grade; lesion with high-grade dysplasia = 1 L4E
| lesions submitted in >1 block: use [[L4E rule 4 (2018)|L4E rule 4]]
| 2 HP polyps in one block = 1 L4E, 1 tubular adenoma negative for HG dysplasia = 0.5 L4E
| Rule 1 <ref name=capacp2018/> 
|-
| Breast core biopsies & prostate core biopsies
| 1 L4E for 1st core + 0.25 L4E for each additional core + 3 L4E for synoptic (if mandated - see [[L4E rule 5 (2018)|L4E rule 5]])
| should use clinicians core count (if available), if clinicians' count not available use gross count
| 4 breast cores = 1.75 L4E<br>12 prostate cores (without synoptic report) = 3.75 L4E<br>12 prostate cores (with synoptic report) = 6.75 L4E 
| Rule 2 <ref name=capacp2018>Workload and Workforce Committee of the CAP-ACP. Workload Measurement Guidelines. Canadian Association of Pathologists (CAP-ACP). 2018. URL: [https://www.cap-acp.org/cmsUploads/CAP/File/CAP-ACP_Workload_Model_2018_Final_2020180907(1).pdf https://www.cap-acp.org/cmsUploads/CAP/File/CAP-ACP_Workload_Model_2018_Final_2020180907(1).pdf]. Accessed on: 19 May 2019.</ref>  
|-
| Core biopsies (not including prostate, breast) 
| 1 L4E / 5 cores, all fractions are rounded down
| 1-5 cores = 1 L4E, 6-10 cores = 2 L4E, 11-15 cores = 3 L4E, 16-20 cores = 4 L4E
| 3 cores of lymph node = 1 L4E, 6 cores of mediastinal mass = 2 L4E
| Rule 2 <ref name=capacp2018/>  
|-
| Fragmented tissue/ curettage
| 1 L4E / 3 blocks, all fractions are rounded down
| 1-3 blocks = 1 L4E, 4-6 blocks = 2 L4E, 7-9 blocks = 3 L4E, 10-12 blocks = 4 L4E, 13-15 blocks = 5 L4E, 16-18 blocks = 6 L4E, 19-21 blocks = 7 L4E
| endometrial biopsy in 2 blocks = 1 L4E, TURP in 7 blocks = 3 L4E, bladder biopsy in 12 blocks = 4 L4E
| Rule 3 <ref name=capacp2018/> 
|}

==Tutorial==
The following cases can be used to work through the above rules. If one clicks "Expand" on the right side one gets the answer with an explanation. It is presumed that no additional stains or levels are done.
{{hide3|1. Three cores of a neck lymph node. L4E?|Answer: 1 L4E<br>Why? Rule 1: 1-5 frags ~ 1 L4E; see ''complex skin biopsies and non-GI biopsies with countable fragments'' }}

{{hide3|2. Six cores of a mediastinal mass. L4E?|Answer: 2 L4E<br>Why? Rule 1: 6-10 frags ~ 2 L4E; see ''complex skin biopsies and non-GI biopsies with countable fragments''}}

{{hide3|3. Two punch biopsies of BCC. L4E?|Answer: 1 L4E<br>Why? Rule 1: each (simple skin) biopsy is 1 L3}}

{{hide3|4. Two punch biopsies (centre of lesion + edge of lesion) for an inflammatory skin lesion. L4E?|Answer: 1 L4E<br>Why? Rule 1: complex skin biopsies for same purpose}}

{{hide3|5. Colonic tubular adenoma negative for HGD. L4E?|Answer: 0.5 L4E<br>Why? Rule 1: 1 L3/lesion; see ''surgical GI biopsies (neoplastic/pre-neoplastic)''}}

{{hide3|6. Colonic tubular adenoma with HGD. L4E?|Answer: 1 L4E<br>Why? Rule 1: HGD makes it worth more; see ''surgical GI biopsies (neoplastic/pre-neoplastic)''}}

{{hide3|7. Colonic tubular adenoma negative for HGD and hyperplastic polyp in same container. L4E?|Answer: 1 L4E<br>Why? Rule 1: 1 L3 for TA, 1 L3 for HP - together ~ 1 L4E}}

{{hide3|8. Random colonic biopsies 15 frags. L4E?|Answer: 2.5 L4E<br>Why? Rule 1: 15 frags x L3/3 frags ~ 5 L3, 5 L3 ~ 2.5 L4E}}

{{hide3|9. Random colonic biopsies 20 frags. L4E?|Answer: 3 L4E<br>Why? Rule 1: 20 frags x L3/3 frags ~ 6.66 L3 -> truncated to 6 L3, 6 L3 ~ 3 L4E}}

{{hide3|10. Prostate biopsy with 12 cores without synoptic report. L4E?|Answer: 3.75 L4E<br>Why? Rule 2: 1 L4E (first core) + 11 cores x 0.25 L4E/core ~ 3.75 L4E}}

{{hide3|11. Breast biopsy with 2 cores. L4E?|Answer: 1.25 L4E<br>Why? Rule 2: 1 L4E + 0.25 L4E ~ 1.25 L4E}}

{{hide3|12. Endometrial biopsy in 2 blocks. L4E?|Answer: 1 L4E<br>Why? Rule 3: 1-3 blocks ~ 1 L4E}}

{{hide3|13. Benign TURP in 4 blocks. L4E?|Answer: 2 L4E<br>Why? Rule 3: 4-6 blocks ~ 2 L4E}}

{{hide3|14. Benign TURP in 6 blocks. L4E?|Answer: 2 L4E<br>Why? Rule 3: 4-6 blocks ~ 2 L4E}}

{{hide3|15. Endometrial biopsy in 5 blocks. L4E?|Answer: 2 L4E<br>Why? Rule 3: 4-6 blocks ~ 2 L4E}}

{{hide3|16. Benign TURP in 8 blocks. L4E?|Answer: 3 L4E<br>Why? Rule 3: 7-9 blocks ~ 3 L4E}}

==Quiz==
You can test your knowledge in the ''[[Quiz:L4E rules 1-3 (2018)|L4E rules 1-3 quiz]]''.

==See also==
*[[L4E rules of 2018]].
*[[L4E rule 1-3 (2014)]].

==References==
{{Reflist|1}}

[[Category:Workload]]