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External Cause Codes and Their Many Uses in Utah

External Cause Codes and Their Many Uses in Utah. Cristy Sneddon, RHIT Utah Department of Health. Objectives. External Cause of Injury Codes (E Codes) Mandates and Administrative Code Data and the Violence and Injury Prevention Program (VIPP) Opiate/Opioid Overdose Project

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External Cause Codes and Their Many Uses in Utah

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  1. External Cause Codes and Their Many Uses in Utah Cristy Sneddon, RHIT Utah Department of Health

  2. Objectives • External Cause of Injury Codes (E Codes) • Mandates and Administrative Code • Data and the Violence and Injury Prevention Program (VIPP) • Opiate/Opioid Overdose Project • Unspecified Elderly Falls Project • ED Concussion Data • ICD-10 External Cause Codes

  3. External Cause of Injury Codes • E Codes help us: • Describe the magnitude of injury morbidity by cause of injury • Identify population subgroups at high risk for a particular cause of injury • Bicycle related injuries in children 5 – 14 years • Identify the place of occurrence for specific types of injuries/populations • Elderly falls 65 and older

  4. External Cause of Injury Codes • Develop prevention strategies targeting specific causes of injury and specific population groups at risk • Helmet give-away and educational programs to school-aged children • Exercise programs for elderly adults at risk for falls

  5. External Cause of Injury Codes • Evaluate the effectiveness of the intervention programs • Cost-effectiveness of helmet programs and education in reducing bicycle-related injuries in school-aged children • Monitor elderly fall injury trends to see if rates are decreasing • Source: Public Health Data Standards Consortium. The Importance of Understanding External Cause of Injury Codes Tutorial, 2006.

  6. Historical Perspective • In 1991, the National Committee on Vital and Health Statistics (NCVHS) recommended that external cause of injury codes (E Codes) be included in hospital discharge (HDD) data sets • At that time only 5 states had HDD systems which collected E Codes

  7. Utah Mandates • Utah passed legislation requiring the routine collection of E Codes statewide: • In 1995 for Hospital Discharge Data (HDD) • In 1996, for Hospital Emergency Department Data (HEDD)

  8. Utah Administrative Code • Rule 428-10 • Health Data Authority Hospital Inpatient Reporting Rule • HDD Code • Rule 386-703 • Injury Reporting Rule • Injury Reporting Rule

  9. A Snapshot of 2011 • 11,571 Utahns were hospitalized due to an injury or violent act • 31 people hospitalized every day • 154,047 Utahns were treated in an ED • Enough people to fill Energy Solutions Arena 8 times • Source: Violence and Injury Prevention Program website, http://www.health.utah.gov/vipp/index.html; and Utah’s Indicator Based Information System for Public Health (IBIS-PH), 2011 data [cited 2013 August]

  10. VIPP Background • The Violence and Injury Prevention Program (VIPP) has been gathering Injury data and providing prevention resources for 30 years. • Majority of programs are Federally funded from the Centers for Disease Control and Prevention (CDC)

  11. VIPP Background • Prevention Programs include: • Traumatic Brain Injury • Spinal Cord Injury • Falls Among Older Adults • Prescription Drug Overdose • Rape and Sexual Assault • Student Injury • Infant Sleep Death

  12. VIPP Background • Prevention Programs include: • Teen Driving • Safe Kids • Child Abuse and Maltreatment • Dating and Domestic Violence • Motor Vehicle Crashes • Violent Death (Homicide, Suicide, Undetermined)

  13. Current Projects • Opiate/Opioid Overdose Hospitalization Project • Unspecified Elderly Falls Project • Traumatic Brain Injury (TBI) Surveillance, Emergency Department Concussion Data

  14. Current Projects Opiate/Opioid Overdose Hospitalizations

  15. Surveillance Quality Improvement (SQI) • In 2011, Utah was one of four states to receive Surveillance Quality Improvement (SQI) Grant • UT, CO, NC, MA • 5 year grant cycle • Every year the multi-state group, including CDC, decides on a project pertinent to emerging public health conditions

  16. Surveillance Quality Improvement (SQI) • Year 2 Multi-State Project • Accidental Opiate/Opioid Overdose • ED or Inpatient (Utah chose inpatient) • Year 2 Individual State Project • Suicide and Undetermined intent • Determine the complete inpatient overdose picture

  17. Criteria • Report from the Injury Surveillance Workgroup on Poisoning (ISW-7) for National and State Poisoning Surveillance • ISW-7 • The Safe States Alliance is a national non-profit 501(c)(3) organization and professional association whose mission is to strengthen the practice of injury and violence prevention

  18. Criteria • Standardized code set for ICD-9-CM opiate/opioid poisoning and associated E Codes • 965.00, 965.01, 965.02, 965.09 • Accidental; E850.0, E850.1, E850.2 • Suicide; E950.0, E950.4, E950.5 • Undetermined; E980.0, E980.4, E980.5

  19. Criteria • Determine PPV (Positive Predictive Value) for both sets of codes • Documentation of one or more of the following clinical signs to verify Opioid Analgesic Overdose: • Respiratory depression • Miosis • Stupor • Rhabdomyolysis • Myoglobinuric Renal Failure • Compartment Syndrome

  20. Criteria • Use of Naloxone as treatment for overdose either given in the hospital or prior to arrival • Medical record documentation to support coded intention • Clinical Signs Source: The New England Journal of Medicine, Management of Opioid Analgesic Overdose, July 12, 2012

  21. Opiate/Opioid Overdose • Pulled code criteria from 2011 data year • Total of 842 inpatient hospitalizations for record review • Accidental – 346 • Suicide – 224 • Undetermined – 77 • Cases with ICD-9 poison code, but no E code for intent - 195

  22. Opiate/Opioid Overdose • PPV Results for ICD-9 Poison codes

  23. Opiate/Opioid Overdose • PPV for E Codes and intent of injury • Sensitivity: actual positive cases which are correctly identified as such

  24. Uses for Opiate/Opioid Data • Information shared with the Prescription Drug Task Force • Multi-state Special Emphasis Report – Drug Overdose Morbidity • Naloxone study • Naloxone study results presented at the Safe States Alliance Conference • Naloxone poster presented at the Council of State and Territorial Epidemiologist (CSTE)

  25. Uses for Opiate/Opioid Data • Naloxone Study • Medical record review process included administration of Naloxone • 57% of hospitalizations given Naloxone • Findings: Early administration of drug associated with discharge to home instead of other location or death • Helped inform legislators and supports new Naloxone law passed last session

  26. Uses for Opiate/Opioid Data • H.B. 119 – Opiate Overdose Emergency Treatment • Permits administration of Naloxone to someone experiencing overdose • Immunity for good faith • Doctors can prescribe Naloxone to: • Person at risk of opiate-related overdose • Family member, friend or other person in a position to assist someone who is a user of pain killers or Heroin

  27. Findings • 842 cases reviewed, 2 cases found to be false positive (FP) • First FP case coded - 965.09, Other opiate (Codeine, Morphine Meperidine); E850.2, Accidental Other opiate and related narcotic; E850.4, Accidental Aromatic analgesics • On review, case was found to be accidental Methamphetamine overdose (969.2, E854.2)

  28. Findings • Second FP case coded - 965.09, Other opiate (Codeine, Morphine Meperidine); E950.0, Suicide and self-inflicted Analgesics, Antipyretics and Antirheumatics • On review, patient admitted for suicidal ideation • No mention of overdose • No medication mentioned • All lab results negative

  29. Findings • Total positive cases - 840 • Found documentation to ‘revise’ 42 cases WAIT!!

  30. No Reason to be Alarmed • Please remember and don’t panic • When talking about ‘revising’ or ‘being able to revise’ E Codes we don’t remove or change original coding • We add additional variables for surveillance coding comparison

  31. Findings • Total positive cases - 840 • Found documentation to ‘revise’ 42 cases • 5 with correct poison code, no E codes listed • 2 coded as accidental, but documentation stated suicide intent • 1 case had both suicide and undetermined intent codes listed • 2 cases had correct poison, but listed E858.8 other specified drug • One case had diagnosis of Opiates and Benzodiazipines NOS (E850.2, E853.2) • One case had diagnosis of Opiates NOS (E850.2)

  32. Findings • Most alarming • Found 15 cases coded as Suicide • 35.7% of total cases ‘revised’ • Documentation found stated Accidental • Verified with individual hospital coding supervisors • Wanted to make double sure we didn’t miss anything • Determined to be confusion and coding training issue • On a larger scale… • Total of 224 inpatient suicide overdose cases • 15 cases represents 6.7% which has potential to affect (skew) our percentage and rates nationally

  33. Findings • ICD-9 poisoning codes • Several cases had missing or incorrect codes • Had Opiate code, missed Methadone • Had Heroin coded as 965.00 instead of 965.01 • Had Heroin listed on diagnosis, not coded • 965.00 vs. 965.09 • Found multiple cases where original code was 965.00 • On case review felt should be coded as 965.09 as there was a ‘named’ drug

  34. Discussion • 965.00 vs. 965.09 • Under the impression that a drug that is NOS or generic is coded 965.00 • Named drugs, such as Oxycodone would be coded as 965.09 CodingKnowledge Thoughts? Comments? Insight?

  35. Current Projects Unspecified Elderly Fall Hospitalizations

  36. Surveillance Quality Improvement (SQI) • Year 3 Individual SQI State Project • Elderly falls is an emerging public health condition • Project focused in this area

  37. Standard Definitions • Standard Definitions • Fall: • An event which results in a person coming to rest on the ground or other lower level precipitated by a misstep such as a slip, trip, stumble; from loss of grip or balance; from jumping; or from being pushed, bumped, or moved by another person, animal or inanimate object or force • Fall-Related Injury: • An injury precipitated by a fall (as defined above) and caused by striking an injury-producing surface

  38. Criteria • National Report from the Injury Surveillance Workgroup on Falls (ISW-4) • ISW-4 • Specific set of fall related E Codes • E880-E886, E888, E957, E968.1, E987 • Also included Utah identified codes; E917.8, Striking against other stationary object with fall; and E917.7 Striking against furniture with fall

  39. Criteria • Utah specific Criteria • Utah resident • 65 and older • Acute care inpatient hospitalization

  40. Unspecified Falls Project • Data taken from 2012 HDD • Total of 4,369 cases met criteria • Significant issue to explore • 1,682 identified cases had an Unspecified Fall E Code (E888.9) • 38.5% of total fall cases

  41. Unspecified Falls Project • Random Sample of 350 cases (20.8%) • Determine if documentation available for more specific E Code • Identified 137 cases with documentation for more specific code (39.1%) • Utah refers to ‘revise’ • Don’t remove or change original coding, add additional variables for surveillance coding comparison

  42. Unspecified Falls Project • Graph showing 137 cases before

  43. Unspecified Falls Project • Referring to the previous graph what kind of information can you get? • In terms of fall prevention, what information can you get? • What type of falls are happening?

  44. Unspecified Falls Project • Graph showing 137 cases before

  45. Unspecified Falls Project • Now using ‘revised’ codes……..

  46. Uses for Unspecified Falls Data • Information shared with Utah Falls Prevention Coalition • Fact Sheets to share data with local health departments and other partners • Multi-state Special Emphasis Report on Elderly Falls • Show need for programs such as Stepping On and Matter of Balance • Scientifically tested and proven interventions

  47. Current Projects Traumatic Brain Injury Surveillance

  48. Traumatic Brain Injury (TBI) • Previous presentations looked at Inpatient hospital data • Focus on E Codes from reviewed cases • Specifically looking at coding differences and findings

  49. TBI ED Data • Standard case definition for TBI Surveillance taken from the Center for Disease Control and Prevention (CDC) • Same code set as Inpatient • Code sets for both Morbidity and Mortality (our focus for this presentation is Morbidity)

  50. Criteria • Opiate/Opioid project used both ICD-9-CM and E Codes to determine injury • Unspecified Elderly Falls Project used only E Codes to determine injury • TBI data for both inpatient and ED is pulled strictly by ICD-9-CM diagnosis codes

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