Trauma Registry Q&A: “Can we ever use medical record codes?”

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Trauma data experts have always discouraged registrars from using medical record codes. But with the implementation of ICD-10, registry leaders are rethinking this recommendation. In this month’s “Trauma Registry Q&A” column, trauma registry experts from Pomphrey Consulting explain when and how it is acceptable to populate your trauma registry with medical record codes.

Q. We used to hear that trauma registrars should never use medical record codes. What’s different now?

Before ICD-10, we strongly advocated that trauma registrars not use medical record codes. Since medical coders code for financial reimbursement, not injury, the medical record is not a fully reliable source of trauma care data. So our “blanket recommendation” has always been to keep medical record data out of the trauma registry.

However, with the implementation of ICD-10 and its complexities, many hospitals are struggling to maintain a concurrent trauma registry. Given this situation, it makes sense to step back, reevaluate the issues and identify the specific ways in which trauma registrars can use medical records data to work more efficiently while still maintaining accuracy.

Q. When is it acceptable to use medical record codes in the trauma registry?

To answer this question, let’s first review that there are three major components of ICD-10 — external cause codes, procedure codes and injury codes.

External cause codes, which record the mechanism of injury, are very straightforward and difficult to get wrong. Given this, it is okay to use medical record external cause codes in your trauma registry.

Procedure codes are also very straightforward. Since procedure coding drives reimbursement, hospital coders have had to become proficient in coding procedures in ICD-10. As a result, the procedure code in the medical record is generally reliable and can be used in the trauma registry. In addition, procedure codes do not affect trauma benchmarking reports, so they present a low risk in terms of trauma data quality.

However, one caution is in order here. Medical record procedure codes do not include the date and time of service. So if you download medical record procedure codes for use in your trauma registry, you still need to go into the chart and find the dates and times for all the procedures. After you have the procedure dates and times, you then need to match them to the medical record procedure codes.

Q. Is it OK to import medical record injury codes into the trauma registry?

No, registrars should not import medical record injury codes into the trauma registry. Since hospital medical coders code for reimbursement, the medical record only includes the injury code that is sufficient to trigger the DRG. For example, if a patient has a femur fracture, the medical record injury code will often be “femur fracture unspecified.” But since injury codes impact injury severity scores, trauma registry codes must be as specific as possible, especially under ICD-10. A trauma registrar would need to code the same femur fracture as right versus left, open versus closed, etc.

Having said that, trauma registrars can use medical record injury codes as a tool for ensuring data quality. For example, a quick review of the medical record could allow a trauma registrar to catch injuries that were coded in the medical record but missed in the chart abstraction process.

However, if you do use medical record injury codes as part of your “quality check,” be sure to verify date of injury. Under ICD-10 rules, medical records might now include codes for injuries sustained months or years in the past. Trauma registrars should be careful to abstract only the injury codes that are applicable to the current date of service.

Trauma Registry Q&A is a monthly column produced in partnership with Pomphrey Consulting, a comprehensive trauma registry company which provides training and trauma registry management. The American College of Surgeons has recognized our Trauma Registrar Mentorship Program for meeting the trauma registrar course requirement of CD15-7. Our course is revised each year to meet any and all ACS NTDB changes, as well as the demands of the ever-changing world of trauma registries. Our program also includes full trauma registrar training in ICD-10-CM and ICD-10-PCS. To visit our website, click here.