Ms Nichola Foster1,2,3, Dr Edward Raby3,5, Prof Fiona M. Wood3,5, Dr Mark Fear3,5, Dr Nathan Pavlos4, A/Prof Dale W. Edgar2,3,5,6
1Physiotherapy Department, Sir Charles Gairdner Osborne Park Health Care Group, North Metropolitan Health Service, Nedlands, Australia, 2Burn Injury Research Node, Institute for Health Research / School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia, 3Burn Injury Research Unit and Fiona Wood Foundation, University of Western Australia, Nedlands, Australia, 4School of Biomedical Sciences, University of Western Australia, Nedlands, Australia, 5State Adult Burn Unit, Fiona Stanley Hospital, Murdoch, Australia, 6Department of Physiotherapy, Royal Perth Hospital, Perth, Australia
Abstract:
Background:
Traumatic heterotopic ossification (tHO) is the pathological formation of ectopic bone in soft tissues following burn, neurological, or orthopaedic trauma. As completeness and accuracy of medical diagnostic coding can vary due to institutional documentation practices, it is important to assess diagnostic coding in that local context. To the authors’ knowledge, there is no prior study evaluating the accuracy of medical diagnostic coding or specificity of clinical documentation for tHO diagnoses across WA hospitals or across the full range of inciting injury and surgical events.
Objective:
To assess the accuracy of ICD-10-AM coding for tHO and evaluate clinical documentation across four WA hospitals.
Methods:
A retrospective review of the WA trauma database identified tHO cases following burn, neurological, or orthopaedic trauma. Demographics and diagnostic characteristics were assessed. The frequency and distribution of M61 (HO-specific) and broader, musculoskeletal (non-specific) ICD-10-AM codes were evaluated for tHO cases in each trauma population.
Results:
M61 codes failed to identify over a third of true tHO cases, with 19.4% classified under non-specific codes and 25.4% identified via manual chart review. Sensitivity for diagnosing tHO post-burn injury was 50%. ROC analysis showed M61 codes were a suboptimal predictor of true tHO cases (AUC=0.731, 95% CI=0.561–0.902, p=0.012). Marked variability in clinical documentation was identified across hospitals.
Conclusion:
Coding inaccuracies, influenced by inconsistencies in clinical documentation, may impact patient care and future research outcomes. Clinicians should consistently employ standardised clinical terminology from the point of care to increase the likelihood of accurate medical diagnostic coding for tHO diagnoses
Biography:
Dr. Nichola Foster is a senior physiotherapist and researcher. She holds a PhD from the University of Notre Dame, Australia, where her research focused on the pathophysiological mechanisms, epidemiological characteristics, and risk factors of Traumatic Heterotopic Ossification, a devastating complication of burn, neurological and orthopaedic trauma. Her work has contributed to advancing diagnostic accuracy and understanding the molecular pathways underlying this condition. Nichola currently serves as a Senior Physiotherapist in Oncology, Haematology, and Prehabilitation at Sir Charles Gairdner Hospital, with a commitment to evidence-based practice and interdisciplinary collaboration. In addition to her clinical and research roles, Nichola is a sessional academic at Curtin University, where she mentors physiotherapy students. She is passionate about advancing practice through research, education, and collaboration, fostering a healthcare environment that prioritises excellence and innovation.