Suicidal Behavior and Non-Suicidal Self-Injury in Emergency Departments Underestimated by Administrative Claims Data

External causes of injury codes (E-codes) are used in administrative and claims databases for billing and often employed to estimate the number of self-injury visits to emergency departments (EDs).

This study assessed the accuracy of E-codes using standardized, independently administered research assessments at the time of ED visits.

We recruited 254 patients at three psychiatric emergency departments in the United States between 2007 and 2011, who completed research assessments after presenting for suicide-related concerns and were classified as suicide attempters (50.4%, n = 128), nonsuicidal self-injurers (11.8%, n = 30), psychiatric controls (29.9%, n = 76), or interrupted suicide attempters (7.8%, n = 20). These classifications were compared with their E-code classifications.

Of the participants, 21.7% (55/254) received an E-code. In all, 36.7% of research-classified suicide attempters and 26.7% of research-classified nonsuicidal self-injurers received self-inflicted injury E-codes. Those who did not receive an E-code but should have based on the research assessments had more severe psychopathology, more Axis I diagnoses, more suicide attempts, and greater suicidal ideation.

The sample came from three large academic medical centers and these findings may not be generalizable to all EDs.

The frequency of ED visits for self-inflicted injury is much greater than current figures indicate and should be increased threefold.