3088 — External Cause of Injury Coding in VA Polytrauma Patient Discharge Records: Use and Accuracy across Rehabilitation Center Sites

Carlson KF (Minneapolis VAMC), Sayer NA (Minneapolis VAMC), Chiros C (Minneapolis VAMC), Nugent S (Minneapolis VAMC), Grill J (Minneapolis VAMC)

Objectives:
Veterans from Operations Iraqi Freedom/Enduring Freedom (OIF/OEF) are using VA services for injuries incurred during and after their military service. The objectives of this study were to: a) determine whether ICD-9 supplemental external cause-of-injury codes (e-codes) can be used to identify causes of injury among OIF/OEF VA users, and b) identify sources of variation in coding practice across VA Polytrauma Rehabilitation Centers (PRCs).

Methods:
We reviewed CPRS chart notes for 566 consecutive patients treated at one of 4 PRCs between 2001 and 2006 and who served after the Persian Gulf War. A certified medical records coder and an experienced injury epidemiologist assigned “gold standard” e-codes to each patient based on the same CPRS chart notes used by VA coders. Gold standard coders were blinded to e-codes already assigned by VA coders. VA diagnosis and e-codes were extracted from VISTA. Analyses included descriptive summaries based on gold standard e-codes and measures of agreement between gold standard and VA e-codes by major source-of-injury categories.

Results:
Most (95%) PRC patients were male. Ages were 18-59 years (mean=26; SD=7). The majority (n=514; 91%) received rehabilitation for externally-caused injuries. Injuries for 181 patients (35%) were incurred during OIF/OEF deployment. Based on gold standard e-codes, the most frequent sources of injury included motor vehicles (n=280; 55%), blasts/bullets (n=132; 26%), falls (n=38; 7%), and intentional harm (5%), including suicide attempts (n=4) and assaults (n=24). Only 381 (74%) records were assigned e-codes by VA coders. Therefore, kappa values for agreement between gold standard and VA e-codes were poor. Sources of variability in agreement were facility, combat-relatedness, and source-of-injury. For example, kappa values ranged from .62 for motor vehicles, to .77 for blasts/bullets.

Implications:
VA coders are not assigning e-codes to all patients receiving inpatient rehabilitation for externally-caused injuries. E-codes are not a reliable source of information on cause of injury.

Impacts:
VA needs valid, cost-efficient strategies for identifying causes of patient injuries. Although e-codes were developed for this purpose, current VA e-coding practices are not reliable. Identified sources of variation in VA e-coding practices can be used to inform quality improvement efforts.