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Financial Impact of Inaccurate Coding Plus Cost-Effectiveness Analysis for Surgically Managed Patients With
Ethan Toner1, Ahmad Khaled2, Ashwanth Ramesh3
1Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, GBR.
Cureus
|March 8, 2021
Summary
Coding errors in periprosthetic fracture management lead to significant financial losses. Improving documentation and revising Healthcare Resource Group (HRG) tariffs are crucial for accurate financial reimbursement.
Area of Science:
- Orthopedic Surgery
- Health Economics
- Medical Coding
Background:
- Periprosthetic fractures are increasing, requiring complex and costly surgical interventions.
- Hospital reimbursement relies on accurate coding of diagnoses, procedures, comorbidities, and length of stay.
- Existing auditing systems may not prevent coding inaccuracies, leading to potential financial losses.
Purpose of the Study:
- To evaluate the accuracy of coding for periprosthetic fracture management.
- To identify the root causes of coding inaccuracies.
- To assess the financial impact of complex trauma coding in a district general hospital.
Main Methods:
- Retrospective analysis of patient case notes with M966 diagnosis code (periprosthetic fracture).
- Re-coding of data including primary/secondary diagnoses, procedures, comorbidities, and length of stay.
- Calculation of incurred costs and comparison with actual financial claims for cost-effectiveness analysis.
Main Results:
- Coding accuracy for surgically managed periprosthetic fractures was 52%, resulting in an estimated £25,000 loss.
- Incorrect or omitted surgical site coding was the most significant error, causing up to £8,000 loss per case.
- Healthcare Resource Group (HRG) tariffs showed significant discrepancies in trauma settings compared to non-trauma settings.
Conclusions:
- Surgeons must meticulously review procedure codes for complex cases like periprosthetic fractures.
- Inaccurate coding, particularly regarding surgical site and comorbidities, drives financial losses.
- Current HRG tariffs require revision to reflect the true costs of managing complex orthopedic trauma, especially differentiating between procedures like open reduction and internal fixation (ORIF) versus massive endoprosthesis implantation.
