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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.
Insights
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.
Abstract:
Background An upward trend is seen in a number of periprosthetic fractures. Their management often requires complex surgical intervention, expert skills and expensive equipment. Hospitals get paid according to Healthcare Resource Group (HRG) tariffs. HRG gets generated once diagnoses, Charlson comorbidity (CC) index score, surgical procedures, investigations and length of stay have been coded for. Coding departments consist of non-clinicians. Although auditing systems are in and made of internal and external auditors, we hypothesized that multiple errors can still occur which may result in significant financial losses. Objectives To assess the accuracy of coding for management of periprosthetic fractures. To identify causes for inaccurate coding and assess the financial impact of highly complex trauma in a district general hospital (DGH). Methods Retrospective comparative analysis of case notes for patients with an M966 diagnosis code (periprosthetic fracture) between 1st November 2017 and 1st November 2018. All cases were analysed and data for primary procedure, primary diagnosis, secondary procedures and secondary diagnosis, comorbidities and length of stay were extrapolated and re-coded using the same software in use by the coding team. Costs incurred for each surgically managed patient were calculated using a rough estimate of cost of each procedure. Finally, cost-effectiveness analysis was carried out by comparing our calculated figures to the actual final claim by our institution. Results Twenty-nine patients with the diagnosis of periprosthetic fracture were identified by the coding team using M966 code. A further case was identified by reviewing operating software (Operating Room Management Information System [ORMIS®]). In four cases (13.3 %), the primary diagnosis was coded incorrectly by the coding team. Overall coders accuracy for surgically managed patients (n=21) was 52% (n=11). This resulted in an estimated incurred loss of £25,000. Wrong/omitted site of surgery was found to be the most influential coder error with up to £8000 loss in one case (P<0.05). Cost-effectiveness analysis demonstrated the stark differences in costs for HRG tariffs when used in trauma setting vs non-trauma setting. Open reduction and internal fixation (ORIF) was associated with less financial loss to our trust with closer procedural costs to HRG tariff (average cost of £9200 for ORIF vs £22,030 for a massive endoprosthesis). Conclusions Surgeons should carefully review codes for such complex procedures before or soon after surgery. Wrong/omitted site of surgery is the key cause for losses in our cohort, followed by inadequate recording of comorbidities. Coders can only code for what is documented. Following cost-effectiveness analysis our study highlights the need for HRG tariffs to be revised for such procedures. The cost of ORIF vs massive endoprosthesis should be noted, signifying the implant costs when such specialised revision surgery performed over less expensive ORIF surgery.
