Evaluation of the Accuracy of Diagnostic Coding and Clinical Documentation for Traumatic Heterotopic Ossification Diagnoses in Western Australian Tertiary Hospitals

14 Pages Posted: 19 Sep 2023

See all articles by Nichola Foster

Nichola Foster

University of Notre Dame Australia

Edward Raby

The University of Western Australia - Fiona Stanley Hospital

Fiona Wood

The University of Western Australia - Fiona Stanley Hospital

Mark Fear

The University of Western Australia

Nathan Pavlos

The University of Western Australia

Dale Edgar

The University of Western Australia - Fiona Stanley Hospital

Abstract

Background: Traumatic heterotopic ossification (tHO) refers to the pathological formation of ectopic bone in soft tissues that can occur following burn, neurological or orthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary based on coding practices and, is dependent 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 the diagnosis of tHO across Western Australia (WA) trauma centres, or across the full range of inciting injury and surgical events.

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 tertiary hospitals.Methods: A retrospective data search of the WA trauma database was conducted to identify patients with tHO admitted to WA tertiary hospitals following burn, neurological or orthopaedic trauma. Patient demographic and tHO diagnostic characteristics for all inpatient and outpatient tHO diagnoses was assessed. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes was evaluated for tHO cases in each trauma population.

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 was 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: 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 the use of standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses.

Note:
Funding declaration: This study was supported through a scholarship provided by The University of Notre Dame, Australia.

Conflict of Interests: None.

Ethical Approval: Ethics approval was granted by the South Metropolitan Health Human Research Ethics Committee (RGS3452) and from The University of Notre Dame, Fremantle (2020-013F). Site Governance approval was granted by South Metropolitan Health Service (Fiona Stanley Hospital), East Metropolitan Health Service (Royal Perth Hospital) and North Metropolitan Health Service (Sir Charles Gairdner Osborne Park Health Care Group).

Keywords: traumatic, heterotopic ossification, spinal cord injury, brain injury, burn injury, orthopaedic injury, ICD-10-AM codes, medical diagnostic coding, SNOMED CT-AU.

Suggested Citation

Foster, Nichola and Raby, Edward and Wood, Fiona and Fear, Mark and Pavlos, Nathan and Edgar, Dale, Evaluation of the Accuracy of Diagnostic Coding and Clinical Documentation for Traumatic Heterotopic Ossification Diagnoses in Western Australian Tertiary Hospitals. Available at SSRN: https://ssrn.com/abstract=4572270 or http://dx.doi.org/10.2139/ssrn.4572270

Nichola Foster (Contact Author)

University of Notre Dame Australia ( email )

Sydney, 2000
Australia

Edward Raby

The University of Western Australia - Fiona Stanley Hospital ( email )

Australia

Fiona Wood

The University of Western Australia - Fiona Stanley Hospital ( email )

Australia

Mark Fear

The University of Western Australia ( email )

35 Stirling Highway
Crawley, 6009
Australia

Nathan Pavlos

The University of Western Australia ( email )

Dale Edgar

The University of Western Australia - Fiona Stanley Hospital ( email )

Australia

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