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Does clinical evidence support ICD-9-CM diagnosis coding of complications?
E P McCarthy1, L I Iezzoni, R B Davis
1Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, the Charles A Dana Research Institute, Boston, Massachusetts 02215, USA. Ellen_Mccarthy@caregroup.harvard.edu
Insights
This study found that clinical evidence often did not support hospital discharge diagnoses coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), raising concerns for quality monitoring.
Area of Science:
- Medical Informatics
- Health Services Research
- Clinical Epidemiology
Background:
- Hospital discharge diagnoses, coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), are crucial for reimbursement and quality monitoring.
- Previous validity studies focused on coding guideline adherence, not the presence of the actual clinical condition.
Purpose of the Study:
- To assess whether clinical evidence in medical records substantiates selected ICD-9-CM discharge diagnoses.
- To evaluate the clinical validity of ICD-9-CM codes used in quality monitoring programs.
Main Methods:
- Retrospective review of 485 hospitalizations of elderly Medicare beneficiaries.
- Analysis of the proportion of patients with specific ICD-9-CM codes who had supporting clinical evidence.
Main Results:
- While most postoperative acute myocardial infarction diagnoses were supported, fewer than 60% of other diagnoses had confirmatory clinical evidence.
- 30% of medical and 19% of surgical patients lacked objective evidence for their coded diagnoses.
- Support for coded complications varied, with some relying heavily on physician notes rather than explicit criteria.
Conclusions:
- The presence of clinical conditions for ICD-9-CM codes used in quality monitoring is questionable.
- Findings indicate significant concerns regarding the clinical validity of ICD-9-CM codes for healthcare quality assessment.
Background:
Hospital discharge diagnoses, coded by use of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), increasingly determine reimbursement and support quality monitoring. Prior studies of coding validity have investigated whether coding guidelines were met, not whether the clinical condition was actually present.
Objective:
To determine whether clinical evidence in medical records confirms selected ICD-9-CM discharge diagnoses coded by hospitals.
Research Design And Subjects:
Retrospective record review of 485 randomly sampled 1994 hospitalizations of elderly Medicare beneficiaries in Califomia and Connecticut.
Main Outcome Measure:
Proportion of patients with specified ICD-9-CM codes representing potential complications who had clinical evidence confirming the coded condition.
Results:
Clinical evidence supported most postoperative acute myocardial infarction diagnoses, but fewer than 60% of other diagnoses had confirmatory clinical evidence by explicit clinical criteria; 30% of medical and 19% of surgical patients lacked objective confirmatory evidence in the medical record. Across 11 surgical and 2 medical complications, objective clinical criteria or physicians' notes supported the coded diagnosis in >90% of patients for 2 complications, 80% to 90% of patients for 4 complications, 70% to <80% of patients for 5 complications, and <70% for 2 complications. For some complications (postoperative pneumonia, aspiration pneumonia, and hemorrhage or hematoma), a large fraction of patients had only a physician's note reporting the complication.
Conclusions:
Our findings raise questions about whether the clinical conditions represented by ICD-9-CM codes used by the Complications Screening Program were in fact always present. These findings highlight concerns about the clinical validity of using ICD-9-CM codes for quality monitoring.