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

Nichola Foster, Edward Raby, Fiona Wood, Mark Fear, Nathan Pavlos, Dale Edgar

Research output: Working paperPreprint

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. © 2023, The Authors. All rights reserved.
Original languageEnglish
DOIs
Publication statusSubmitted - 2023

Publication series

NameSSRN Electronic Journal
PublisherElsevier
ISSN (Print)1556-5068

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