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

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.