External Cause Codes and Their Many Uses in Utah

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