Evaluation of the accuracy of diagnostic coding and clinical documentation for traumatic heterotopic ossification diagnoses in Western Australian hospitals.

Brain injury Burn injury Heterotopic ossification ICD-10-AM codes, Medical diagnostic coding, SNOMED CT-AU Orthopaedic injury Spinal cord injury Traumatic

Journal

Injury
ISSN: 1879-0267
Titre abrégé: Injury
Pays: Netherlands
ID NLM: 0226040

Informations de publication

Date de publication:
17 Jan 2024
Historique:
received: 05 06 2023
revised: 10 01 2024
accepted: 13 01 2024
medline: 1 2 2024
pubmed: 1 2 2024
entrez: 31 1 2024
Statut: aheadofprint

Résumé

Traumatic heterotopic ossification (tHO) refers to the pathological formation of ectopic bone in soft tissues that can occur following burn, neurological ororthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary based on coding practices and depend on the institutional culture of clinical documentation, it is important to assess diagnostic coding in that local context. To the authors' knowledge, there is no prior study evaluating the accuracy of medical diagnostic coding or specificity of clinical documentation for tHO diagnoses across Western Australia (WA) trauma centres or across the full range of inciting injury and surgical events. To evaluate and compare the clinical documentation and the diagnostic accuracy of ICD-10-AM coding for tHO in trauma populations across 4 WA hospitals. A retrospective data search of the WA trauma database was conducted to identify patients with tHO admitted to WA hospitals following burn, neurological or orthopaedic trauma. Patient demographic and tHO diagnostic characteristics were assessed for all inpatient and outpatient tHO diagnoses. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes were evaluated for tHO cases in each trauma population. HO-specific M61 ICD-10-AM codes failed to identify more than a third of true tHO cases, with a high prevalence of non-specific HO codes (19.4 %) and cases identified via manual chart review (25.4 %). The sensitivity of M61 codes for correctly diagnosing tHO after burn injury was 50 %. ROC analysis showed that M61 ICD-10-AM codes as a predictor of a true positive tHO diagnosis were a less than favourable method (AUC=0.731, 95 % CI=0.561-0.902, p = 0.012). Marked variability in clinical documentation for tHO was identified across the hospital network. Coding inaccuracies may, in part, be influenced by insufficiencies in clinical documentation for tHO diagnoses, which may have implications for future research and patient care. Clinicians should consistently employ standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses.

Sections du résumé

BACKGROUND BACKGROUND
Traumatic heterotopic ossification (tHO) refers to the pathological formation of ectopic bone in soft tissues that can occur following burn, neurological ororthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary based on coding practices and depend on the institutional culture of clinical documentation, it is important to assess diagnostic coding in that local context. To the authors' knowledge, there is no prior study evaluating the accuracy of medical diagnostic coding or specificity of clinical documentation for tHO diagnoses across Western Australia (WA) trauma centres or across the full range of inciting injury and surgical events.
OBJECTIVE OBJECTIVE
To evaluate and compare the clinical documentation and the diagnostic accuracy of ICD-10-AM coding for tHO in trauma populations across 4 WA hospitals.
METHODS METHODS
A retrospective data search of the WA trauma database was conducted to identify patients with tHO admitted to WA hospitals following burn, neurological or orthopaedic trauma. Patient demographic and tHO diagnostic characteristics were assessed for all inpatient and outpatient tHO diagnoses. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes were evaluated for tHO cases in each trauma population.
RESULTS RESULTS
HO-specific M61 ICD-10-AM codes failed to identify more than a third of true tHO cases, with a high prevalence of non-specific HO codes (19.4 %) and cases identified via manual chart review (25.4 %). The sensitivity of M61 codes for correctly diagnosing tHO after burn injury was 50 %. ROC analysis showed that M61 ICD-10-AM codes as a predictor of a true positive tHO diagnosis were a less than favourable method (AUC=0.731, 95 % CI=0.561-0.902, p = 0.012). Marked variability in clinical documentation for tHO was identified across the hospital network.
CONCLUSION CONCLUSIONS
Coding inaccuracies may, in part, be influenced by insufficiencies in clinical documentation for tHO diagnoses, which may have implications for future research and patient care. Clinicians should consistently employ standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses.

Identifiants

DOI: 10.1016/j.injury.2024.111329 PMID: 38296757
pubmed: 38296757
pii: S0020-1383(24)00020-2
doi: 10.1016/j.injury.2024.111329
pii:
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

111329

Informations de copyright

Copyright © 2024. Published by Elsevier Ltd.

Déclaration de conflit d'intérêts

Declaration of competing interest The authors declare that they have no conflicts of interest.

Auteurs

Nichola Foster (N)

Burn Injury Research Node, Institute for Health Research / School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, 6160, Australia; Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia; Physiotherapy Department, Sir Charles Gairdner Osborne Park Health Care Group, North Metropolitan Health Service, Nedlands, Western Australia, 6009, Australia. Electronic address: Nichola.foster@health.wa.gov.au.

Edward Raby (E)

Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia, 6150, Australia.

Fiona M Wood (FM)

Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia, 6150, Australia.

Mark Fear (M)

Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia.

Nathan Pavlos (N)

School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia, 6009, Australia.

Dale W Edgar (DW)

Burn Injury Research Node, Institute for Health Research / School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Western Australia, 6160, Australia; Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Western Australia, 6009, Australia; State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Western Australia, 6150, Australia; Safety and Quality Unit, Armadale Kalamunda Group Health Service, East Metropolitan Health Service, Mt Nasura, Western Australia, 6112, Australia.

Classifications MeSH