Correspondence and Communication
Clinical coding and external causes of injury: The
importance of documentation
Dear Sir,
Injuries are a prominent cause of morbidity globally. In the United Kingdom (UK) alone, there were over 500,000 emergency hospital admissions for injuries within 2014/15.1 Causes of injury are captured in the clinical coding of hospital activity and this data underpins national datasets such as Hospital Episode Statistics (HES). Knowing the context of an injury permits individualised patient care and this information is crucial for surveillance, intervention evaluation and policy creation.2,3 Monitoring patterns in assaults, unintentional injuries and self-inflicted trauma can lead to the creation of injury-prevention programmes which could help reduce the volumes of avoidable hospital admissions.
The International Classification of Diseases (ICD-10) is used for recording all causes of injury ranging from falls through to war operations.4Clinicians are largely unaware of the role or importance of documenting the circum- stances of injuries; specifically the cause and place of occurrence at the time of injury.4,5There has been limited research into the coding of external causes in the UK.3
The author conducted an audit of inpatient admissions to a London children’s hospital between 01/06/2015 and 31/05/2016. The inclusion criterion was an emergency admission under a consultant of plastic & reconstructive surgery and a primary diagnosis of any injury to the body (ICD-10: code range S00eS99).4 Electronic patient records and coding reports were assessed for documentation and recording of a mechanism of injury. In a subsequent one- month period, coders were given access and permission to use Accident & Emergency (A&E) records as a source of supplementary information for coding. Post-interventional changes in the volumes of external causes coded were quantified (Table 1).
In total, 202 of the 419 admissions (48.2%) did not have an external cause documented and coded in the initial
audit period. This was a direct result of this information being absent from the source documentation used for coding. The quantity of monthly admissions missing external cause codes ranged from 29.0 to 64.3% with fig- ures over 60% found in one quarter of the audited months.
After coders were given access to A&E records, external cause documentation and coding was present in all 36 admissions.
The source documentation typically used for clinical coding, such as discharge summaries, significantly lacks information on the circumstances surrounding injuries. This was evident by just under half of the audited admissions not having a cause documented and subsequently coded.
This concurs with the available literature that concludes that medical records and notably discharge summaries typically lack external cause details.3The results challenge the reliability of using coding data for injury mechanism analysis and raise questions on the practically of using de- rivatives of coding data, such as HES, for drivers of research and policy creation. If external cause omission is wide- spread, injury surveillance may be currently grossly underreported with marked effects on patient management and intervention planning.
There is a need to raise awareness on the importance of recording external causes in clinical documentation that is routinely analysed for coding purposes. Education and communication is paramount between clinicians and coding professionals; clearly defining what information is required and the best method of recording it consistently is imper- ative. Audit, before any relevant coding deadlines, would act as a means of quality assurance and should be per- formed frequently to address any arising issues.
External cause codes are not assigned by A&E de- partments5and inpatient coding provides the only oppor- tunity to capture this information within aggregated datasets. In concordance with other studies, A&E docu- mentation was demonstrated to be a reliable source of information for external cause coding.3This was conveyed by all of the admissions having a cause documented and coded after the introduction of the intervention. In the study setting, the A&E information system was a separate entity from the generic electronic patient record and the system was not widely accessible to coders. A single over- arching information system that provides a record of all activity occurring within a hospital setting would improve +MODEL
Please cite this article in press as: Roberts L, Clinical coding and external causes of injury: The importance of documentation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.08.027
Journal of Plastic, Reconstructive & Aesthetic Surgery (2016)xx, 1e2
http://dx.doi.org/10.1016/j.bjps.2016.08.027
1748-6815/ª2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
the veracity of coding; coders could utilise the widest breath of clinical information possible without the limita- tions of accessibility.
Mechanisms should be put in place to ensure that external cause details are recorded within the electronic patient record itself, with a focus on improving notation in discharge documentation. The introduction of structured proformas, educational workshops and reminder prompts on clinical systems could prove useful. The study did not investigate coding accuracy and this has been reported as low as 64% for external causes.2Further study is required to assess current accuracy to ensure the coding data is robust for secondary uses.
Clinicians and managers are encouraged to explore external cause documentation and coding locally. There is a need for a collaborative effort in improving the consistency of circumstantial documentation if we are to maintain momentum in developing innovative injury monitoring and prevention programmes.
Conflict of interest
None.
Funding
None.
References
1. Health & Social Care Information Centre. Hospital episode sta- tistics, admitted patient care - England 2014e15 national sta- tistics. http://www.hscic.gov.uk/catalogue/PUB19124/hosp- epis-stat-admi-summ-rep-2014-15-rep.pdf [Accessibility veri- fied August 5, 2016].
2. McKenzie K, Enraght-Moony E, Walker SM, McClure RJ, Harrison JE. Accuracy of external cause-of-injury coding in hospital records.Inj Prev2009;15(1):60e4.
3. Cunningham J, Williamson D, Robinson KM, Buchanan R, Carroll R, Paul L. The quality of medical record documentation and external cause of fall injury coding in a tertiary teaching hospital.Health Inf Manag2014;43(1):6e15.
4. World Health Organisation.International statistical classifica- tion of diseases and related health problems. 10th revision.
Tabular list, vol. 1. Geneva: World Health Organization; 2016.
5. Clinical Classification Service. National clinical coding standards ICD-10. In: Accurate data for quality information. 4th ed.
Leeds: Health & Social Care Information Centre; 2015.
Luke Roberts Information & Data Quality Analyst, Evelina London Children’s Hopsital, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom E-mail address:[email protected]
9 August 2016 Table 1 The documentation and coding of external causes of injury.
Intervention status
Year Month External cause documented &
coded
No external cause documented &
coded
External cause documented &
coded (%)
No external cause documented &
coded (%)
Total admissions
Pre-intervention 2015 Jun 23 15 60.5% 39.5% 38
Jul 27 13 67.5% 32.5% 40
Aug 16 19 45.7% 54.3% 35
Sep 10 18 35.7% 64.3% 28
Oct 17 13 56.7% 43.3% 30
Nov 17 15 53.1% 46.9% 32
Dec 22 9 71.0% 29.0% 31
2016 Jan 10 18 35.7% 64.3% 28
Feb 17 26 39.5% 60.5% 43
Mar 21 18 53.8% 46.2% 39
Apr 15 15 50.0% 50.0% 30
May 22 23 48.9% 51.1% 45
Post-intervention Jun 36 e 100% e 36
Totals (pre-intervention) (Jun 15eMay 16)
217 202 51.8% 48.2% 419
Totals (including post-intervention month)(Jun 15- Jun 16)
253 202 55.2% 44.8% 455
2 Correspondence and Communication
+MODEL
Please cite this article in press as: Roberts L, Clinical coding and external causes of injury: The importance of documentation, Journal of Plastic, Reconstructive & Aesthetic Surgery (2016), http://dx.doi.org/10.1016/j.bjps.2016.08.027
