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Original Investigation |

Identifying Pediatric Community-Acquired Pneumonia Hospitalizations:  Accuracy of Administrative Billing Codes

Derek J. Williams, MD, MPH1; Samir S. Shah, MD, MSCE2,3; Angela Myers, MD, MPH4; Matthew Hall, PhD5; Katherine Auger, MD6; Mary Ann Queen, MD7; Karen E. Jerardi, MD, MEd3; Lauren McClain, MD1; Catherine Wiggleton, MD, ScM1; Joel S. Tieder, MD, MPH8
[+] Author Affiliations
1Division of Hospital Medicine, The Monroe Carell Jr Children’s Hospital at Vanderbilt and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
2Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
3Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
4Division of Infectious Diseases, Children’s Mercy Hospitals & Clinics and University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
5Children’s Hospital Association, Overland Park, Kansas
6Division of General Pediatrics, University of Michigan, Ann Arbor
7Division of Hospital Medicine, Children’s Mercy Hospital and Clinics and University of Missouri School of Medicine, Kansas City, Missouri
8Division of Hospital Medicine, Seattle Children’s Hospital and the Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
JAMA Pediatr. 2013;167(9):851-858. doi:10.1001/jamapediatrics.2013.186.
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Importance  Community-acquired pneumonia (CAP) remains one of the most common indications for pediatric hospitalization in the United States, and it is frequently the focus of research and quality studies. Use of administrative data is increasingly common for these purposes, although proper validation is required to ensure valid study conclusions.

Objective  To validate administrative billing data for hospitalizations owing to childhood CAP.

Design and Setting  Case-control study of 4 tertiary care, freestanding children’s hospitals in the United States.

Participants  A total of 998 medical records of a 25% random sample of 3646 children discharged in 2010 with at least 1 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code representing possible pneumonia were reviewed. Discharges (matched on date of admission) without a pneumonia-related discharge code were also examined to identify potential missed pneumonia cases. Two reference standards, based on provider diagnosis alone (provider confirmed) or in combination with consistent clinical and radiographic evidence of pneumonia (definite), were used to identify CAP.

Exposure  Twelve ICD-9-CM–based coding strategies, each using a combination of primary or secondary codes representing pneumonia or pneumonia-related complications. Six algorithms excluded children with complex chronic conditions.

Main Outcomes and Measures  Sensitivity, specificity, and negative and positive predictive values (NPV and PPV, respectively) of the 12 identification strategies.

Results  For provider-confirmed CAP (n = 680), sensitivity ranged from 60.7% to 99.7%; specificity, 75.7% to 96.4%; PPV, 67.9% to 89.6%; and NPV, 82.6% to 99.8%. For definite CAP (n = 547), sensitivity ranged from 65.6% to 99.6%; specificity, 68.7% to 93.0%; PPV, 54.6% to 77.9%; and NPV, 87.8% to 99.8%. Unrestricted use of the pneumonia-related codes was inaccurate, although several strategies improved specificity to more than 90% with a variable effect on sensitivity. Excluding children with complex chronic conditions demonstrated the most favorable performance characteristics. Performance of the algorithms was similar across institutions.

Conclusions and Relevance  Administrative data are valuable for studying pediatric CAP hospitalizations. The strategies presented here will aid in the accurate identification of relevant and comparable patient populations for research and performance improvement studies.

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Figure 1.
Study Population

Asterisk signifies categorization of ICD-9-CM codes indicating a condition precluding diagnosis of CAP: (1) trauma or surgical complication; (2) chronic pulmonary disease (eg, cystic fibrosis), airway anomalies, or tracheostomy; (3) aspiration pneumonia; (4) immunodeficiency, cancer, solid organ transplant, or opportunistic infection; and (5) neuromuscular disease (eg, spinal muscular atrophy). CAP indicates community-acquired pneumonia; ICD-9-CM, International Classification of Diseases, 9th Revision, Clinical Modification.

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Figure 2.
Sensitivity and Specificity of 12 ICD-9-CM Code Identification Algorithms for CAP Using 2 Reference Standards

Provider-confirmed CAP (n = 680) (A) and definite CAP (n = 547) (B). Horizontal and vertical bars represent calculated 95% confidence intervals. CAP indicates community-acquired pneumonia; ICD-9-CM, International Classification of Diseases, 9th Revision, Clinical Modification. Algorithm definitions: 1 = primary or any secondary diagnosis of pneumonia or effusion/empyema (1b excludes complex chronic conditions [CCCs]; see Feudtner et al20); 2 = primary diagnosis of pneumonia or effusion/empyema (2b excludes CCCs); 3 = primary diagnosis of pneumonia or effusion/empyema or primary diagnosis of pneumonia-related complication plus any secondary diagnosis of pneumonia or effusion/empyema (3b excludes CCCs); 4 = primary or any secondary diagnosis of pneumonia (4b excludes CCCs); 5 = primary diagnosis of pneumonia (5b excludes CCCs); and 6 = primary diagnosis of pneumonia or primary diagnosis of pneumonia-related complication or effusion/empyema plus any secondary diagnosis of pneumonia (6b excludes CCCs). The ICD-9-CM codes used in the study are as follows: pneumonia, 480.0 to 480.2, 480.8 to 480.9, 481, 482.0, 482.30 to 482.32, 482.41 to 482.42, 482.83, 482.89 to 482.90, 483.8, 484.3, 485, 486, and 487.0; effusion/empyema, 510.0, 510.9, 511.0 to 511.1, 511.8 to 511.9, and 513; and pneumonia-related complication, 38.9, 458.9, 518.81, 790.7, 799.1, 995.91 to 995.92, and 997.3.

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