Cracking the Code: The Unexpected Challenge of Identifying Major Bile Duct Injuries

摘要

The reported rate of major bile duct injury (BDI) after cholecystectomy is 0.2 to 0.5 per cent. We evaluated the accuracy of coding major BDIs integrating both Current Procedural Terminology (CPT) and ICD-9 coding. A retrospective review was conducted for more than 3.5 million members of a large managed health-care organization from January 2007 to December 2013. A total of 56,194 cholecystectomies were captured over this 6-year period. Major BDIs were defined as unintended transection of a major bile duct, Bismuth-Strasberg classification E1-E5, and requiring biliary reconstruction within one year of cholecystectomy. Based on two published study methods (CPT 47760,47765,47780 and ICD-9 code 998.2), 173 possible BDIs were identified. Only 13 (7.5%) were confirmed to have a major BDI. The remaining 160 cases were minor complications or were unrelated to cholecystectomy. This reflects an overall BDI rate of 0.02 per cent, an order of magnitude less than commonly published rates. There is a lack of consistent methodology to identify major bile duct injuries. This calls into question the accuracy of published rates. We suspect that some major injuries were not captured. We recommend a universal clinical registry and specific ICD codes to accurately identify this serious complication. Cholecystectomy IS one of the most common operations performed by general surgeons. In 2006, it was estimated that approximately 917,000 cholecystectomies were performed in the United States annually. Bile duct injury (BDI) is the most dreaded complication of this common operation, often requiring biliary reconstruction. Patients are at postoperative risk for cholangitis, anastomotic strictures, recurrent procedures, and early death. In a large retrospective review of Medicare beneficiaries, an increased hazard ratio for death was found for patients with a common bile duct (CBD) injury compared with those without CBD injury. A previous publication from our group proposed a link between operative technique and avoidance of major BDI, but this association has not been fully established. In an era where competency is defined by outcomes, the ability to code major BDIs accurately may affect surgeon credentialing, health system reimbursement, and most importantly, patient well-being. Therefore, a reliable method of identifying these clinically significant injuries has the potential to provide more accurate data that may lead to improvements in care.