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ICD-9 codes alone may not provide accurate account of autologous breast reconstructions

Researchers found using International Classification of Diseases, Ninth Revision, codes alone to evaluate autologous breast reconstructions could result in incomplete and inaccurate documentation, as many bilateral flap procedures and reoperations may be left unaccounted for.

In a retrospective review, medical records and discharge data were evaluated for 115 patients who underwent immediate or delayed autologous breast reconstruction from Oct. 1, 2008, to May 1, 2013, at one center in Michigan. The researchers used the patients’ medical records as criteria to identify specific autologous procedures performed, along with any perioperative reoperations. Findings were then compared against procedure codes documented in coded discharge data from the hospital. A total of 163 autologous procedures were performed.

In comparing the medical chart records to the discharge coding, the researchers found incorrect coding for 38 (23%) reconstructive procedures. Bilateral reconstruction was incorrectly coded as unilateral in 22 patients, resulting in the omission of 22 flaps; inaccurate coding of one free flap for another free flap in six patients; and other less-frequent coding inaccuracies.

The researchers reported a total of 48 bilateral breast reconstruction procedures with 96 flaps. Of these, 33 (34%) were coded incorrectly in the hospital discharge database.

A majority of omitted procedure codes (21 of 22) were observed for patients who had the same documented procedure on each side; however, only one omitted procedure code occurred in a patient with differing methods of breast reconstruction, according to the researchers.

Among the unilateral breast reconstruction procedures performed in 67 patients, four flaps (6%) were coded incorrectly in the discharge record.

According to the researchers’ findings, unilateral coding sensitivity was 94%, bilateral coding sensitivity was 42%. The specificity was 48% for unilateral coding and 97% for bilateral coding.

A significant number of patients with bilateral reconstructions falsely received only one discharge procedure code, according to the researchers. The sensitivity of bilateral procedure coding for bilateral breast reconstruction was less than 50%, meaning a significant number of bilateral procedures were coded only as unilateral procedures.

The researchers concluded that this could lead to an increase in the calculated complication rates in patients with unilateral reconstructions. – by Abigail Sutton

Disclosures: The researchers report no relevant financial disclosures.