May 15, 2009
Research Examines Reliability Of Clinical And Pathological Diagnoses Of Barrett’s Esophagus
Researchers find electronic coding overestimates prevalence of Barrett's esophagus
In a review of more than 2,000 patients coded for Barrett's esophagus, electronic diagnosis overestimated the prevalence of the disease according to researchers in California. They found that only 61.9 percent of patients assigned a billing diagnosis code for Barrett's esophagus actually had Barrett's esophagus after a manual record review. The study evaluated the accuracy of diagnostic codes for Barrett's esophagus by contrasting codes from electronic databases with diagnoses from a detailed medical record review. Researchers also evaluated the reproducibility of a pathologic diagnosis of Barrett's esophagus between two pathologists and between a single pathologist on two different occasions. The study appears in the May issue of GIE: Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the American Society for Gastrointestinal Endoscopy (ASGE).
Medical coding translates a patient's diagnosis [International Classification of Disease, 9th revision (ICD-9-CM) codes], pathology results [Systematized Nomenclature of Medicine (SNOMED) codes] and procedures [Current Procedural Terminology (CPTÃ®) codes] into universal medical code numbers that can be recorded in an electronic database. Diagnostic and procedure codes are used for a variety of reasons including insurance reimbursement, to track diseases and for statistical analysis. Payers require accurate reporting of diagnosis coding to explain why a service was provided to a patient.
Two reasons may explain the discrepancy between the electronic coding of Barrett's esophagus and the "final diagnosis" from pathology results. First, some physicians will report the diagnosis of Barrett's esophagus (ICD-9-CM code 530.85-Barrett's esophagus) based on visual appearance when the final pathologic diagnosis does not confirm Barrett's esophagus. This scenario can pertain in office and Ambulatory Surgery Center facilities where physicians are likely to choose their own diagnosis code before they receive pathology results. Secondly, hospital-based coders also report "rule out" diagnoses and are thus likely to over-code Barrett's esophagus when the physician includes the possibility of Barrett's esophagus in the visual description.
Barrett's esophagus is a condition where the lining of the esophagus changes due to chronic inflammation, generally from gastroesophageal reflux disease (GERD). Definitive diagnosis requires a biopsy, taken at upper endoscopy, demonstrating replacement of the normal cell lining with one more like the cell lining of the small intestine. This is also known as intestinal metaplasia (IM). Barrett's esophagus itself has no specific symptoms, but this change can increase the risk of esophageal adenocarcinoma (a type of esophageal cancer). Barrett's esophagus can be readily detected during an upper endoscopy but must be confirmed by biopsies (tissue samples that are examined by a pathologist). The intent is to diagnose this condition, treat it medically, and follow it over time to detect changes indicating that a cancer may be developing.
"We found that a pathologic diagnosis of esophageal intestinal metaplasia is highly likely to be reproduced by a separate review of the slides. In addition, the modest intraobserver variation seen for a single pathologist suggests that a proportion of the discordance for pathology reviews between different pathologists may result from somewhat random misclassification rather than from an incorrect reading by the original pathologist," said study lead author Douglas A. Corley, MD, PhD, Division of Research, Kaiser Permanente. "In contrast, a coded diagnosis of Barrett's esophagus was confirmed by record review only 61.9 percent of the time, a number that is likely too low by itself for either clinical or research uses without supplemental manual verification. However, among the substantial proportion of patients who had both a SNOMED (pathology code) and an ICD (billing code) diagnosis, record review confirmed a diagnosis in 85.4 percent."
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