College Corner

Trauma and Coding

What's ICD-9-CM got to do with it?

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Many variables contribute to the assessment, treatment and care of a trauma patient. First the clinical side: a patient is triaged in the field and transported to a nearby acute care hospital. Once the patient's situation is assessed, further treatment is obtained through surgical intervention or transportation to a larger facility that offers a higher level of care. Regardless of injury, once the trauma team is put on alert, the clock starts ticking. Upon arrival, every action, vital sign, test and treatment is documented in the patient's medical record. Life can be lost in a matter of seconds, and split-second decisions are made by the trauma team to ensure a patient's recovery. 

Trauma is not selective: it can happen to anyone at anytime. Many car accident victims are seen in triage. Young male victims of firearm shootings are often seen in larger city trauma centers. Farm accidents occur in rural settings, while falls among elders occur in all settings.  Aside from the initial injury and treatment, questions regarding prevention must be asked. But, where does one obtain the information to analyze trauma injuries and hope for prevention through education? Where does it come from and where is it housed? Here lies the importance of trauma databases, ICD-9-CM codes and the specialists who maintain them.

Every trauma registry across the U.S. abstracts information from a patient's record. Usually, trauma centers have their own specially trained registrars or coders who extrapolate information and submit it annually or as needed (such as during performance improvement) to the state or national databank, which then uses the information for statistics, research and prevention. The following is collected and submitted by the trauma registrar: patient demographics, date, time, type of injury and pre-hospital information, including scene time and first responder data. This is followed by hospital data documenting the patient's treatment. The injury severity scale and abbreviated injury scale are also used. Finally, the chart is coded using ICD-9-CM trauma and procedure codes.

The National Trauma Databank (NTBD) is America's final trauma databank repository. The data submitted is used for scientific research, and it also acts as a benchmark for trauma centers across the U.S. Its ultimate purpose is to maintain all trauma data information. However, many obstacles abound that hinder the ultimate standardization and uniformity of data collected. 

The U.S. Health Resources and Services Administration, along with several interest groups, and the Committee on Trauma, have joined forces to set data element standards through the National Trauma Registry Standardization Project. No longer will state and national trauma registries be forced to deal with inconclusive data lacking in uniformity and definition. Through the help of data conversion programs and data cleaning, trauma data past and present will be "deposited" in the NTBD through a uniform and consistent process. This will ensure the integrity of data collected and make for more accurate research and benchmarking for the industry as a whole. The goals and objectives of the NTDB are as follows:

  • Improve the quality of patient care;
  • Provide an established information system for the evaluation of injury care and preparedness;
  • Develop better injury scoring and outcome measures;
  • Provide a source of data for clinical benchmarking, process improvement and patient safety.

NTBD was born out of a strong need for a systematic trauma care system and commenced in 1989 under the American College of Surgeons. Presently, the NTBD holds more than 1.5 million cases from 565 U.S. trauma centers. Seventy percent of that data is acquired from Level I trauma centers and 53 percent is from Level II centers. The request for data is on an annual basis. 

There is a great demand for consistent and accurate extrapolation of trauma data, not only for the integrity of data warehoused by the NTDB, but also for research and prevention of trauma-related accidents. However, some states do not have statewide trauma databases, and there is no mandate for trauma registries across the U.S. 

I spoke with a trauma registrar from Stanford University and asked what they do with their data. She said because California does not have a statewide trauma databank, they submit data to the NTDB. However, she felt there were a lot of inconsistencies with the data and gave the impression it's a commonly accepted practice because mandated standards are not in place.   This was shocking to hear. From a coding standpoint, if I fail to follow the national coding guidelines, I am at risk for fraud. As HIM professionals, we should be concerned that such standards for uniform collection of trauma data do not currently exist.

Evidence supports the fact that a national standard for trauma data collection should be implemented because of variation in trauma registry coding. This is addressed in an article published in the Journal for American Emergency Medicine, titled "Are Statewide Trauma Registries Comparable?  Reaching for a National Trauma Dataset" The article gives an example of how inconsistent coding practices are in trauma registries across the U.S. Trauma registrars were given the following coding question:

"A 24-year-old FedEx driver was involved in a motor vehicle crash while working. Impact of crash was on driver's side; patient was unrestrained."

Nineteen trauma registrars provided a primary e-code of 812.xx, which states a traffic accident involving two motor vehicles. An additional nine registrars provided an e-code of 819.xx, which states a traffic accident of unspecified nature. Yet others used 825, non-traffic accident of unspecified nature. One state registrar needed more information to code while two were unfamiliar with e-codes. Furthermore, less than half provided a second e-code (street and highway). These inconsistencies restrict the ability to aggregate trauma events, evaluate treatment modalities, benchmark hospital performance, assess epidemiological trends or evaluate the effectiveness of a trauma system.

To overcome these hurdles, uniform data collection is a must. Inclusion and exclusion criteria need to be addressed and implemented. Education of trauma registrars is also pertinent.  These concerns are shared by the NTBD and are being addressed through their program. 

There is a great need for the expertise of HIM professionals in the trauma collection and maintenance field. Those employed in the field are usually registered health information technicians or administrators. Some trauma registrars are licensed practical nurses, emergency medical technicians or other health care professionals. Training is often on-the-job or through workshops. There is a national test that trauma registrars can take to be designated as a certified specialist in trauma registry. Also, certified coding specialists can fill a need as a trauma registrar because it requires attention to detail and knowledge of ICD-9-CM codes. 

Job prospects? The sky is the limit. I can foresee an HIM professional easily attaining an advanced position as a state or national trauma specialist to ensure the integrity of collected trauma data.

For more information on careers as a trauma registrar, visit the American Trauma Society at www.amtrauma.org/index.html.  

Crystal Clack is a coding specialist  pursuing a master's degree in HIIM and IT leadership at the College of St. Scholastica, Duluth, MN.


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