Lau Marisa, Prenner Jonathan L, Brucker Alexander J, VanderBeek Brian L
Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia.
Department of Ophthalmology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
JAMA Ophthalmol. 2017 Jul 1;135(7):791-794. doi: 10.1001/jamaophthalmol.2017.1595.
Insurance billing claim databases represent a growing field of scientific inquiry within ophthalmology. Validating the accuracy of billing claim codes used during the care of diabetic retinopathy is a necessary precursor to fully understanding the underlying data and subsequent results of these types of studies.
To determine the accuracy of diagnostic, procedural, and therapeutic billing codes used in the treatment of diabetic retinopathy.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective medical record review was conducted at 3 clinical practices (1 academic and 2 private). Insured patients with diabetic retinopathy were seen by the practices between 2011 and 2013. Each patient then had every visit for 2 years reviewed twice, once for billing data and the second for data from the medical record. Data were collected and analyzed from October 2015 to July 2016.
The positive predictive value (PPV) and negative predictive value (NPV) for each code of interest. Sensitivity and specificity were secondary outcomes.
A total of 146 patients (mean [SD] age, 60.3 [12.5] years) from 11 physicians had 1072 encounters reviewed over 2 calendar years. Among the included patients, 49.3% were female (n = 72), 48.6% were white (n = 71), 37.0% were black (n = 54), and 18.5% had type 1 diabetes and a mean (SD) hemoglobin A1C level of 7.7% (1.8) (n = 27). Nearly all codes of interest that were used frequently also had a high PPV (range, 89.5%-100%) and NPV (88.6%-100%) including billing codes for intravitreal injection, focal laser, panretinal photocoagulation, laterality of procedure, ranibizumab, bevacizumab, fundus photographs, fluorescein angiography, and optical coherence tomography. Codes that were used infrequently (<20 instances) but still had a high PPV (all 100%) and NPV (99.7%-100%) were codes for aflibercept, triamcinolone, and the dexamethasone implant. Only the codes for infrequently used B-scan ultrasonography (PPV, 69.6%) and subtenon injection (PPV, 100%; NPV, 99.7%, but sensitivity of only 40%) were found to be of questionable accuracy. Other than subtenon injection (40%), all codes were also found to have a high sensitivity (range, 87.6%-100%) and a high specificity (range, 97.2%-100%).
These data suggest diagnostic, procedure, and therapeutic codes derived from insurance billing claims accurately reflect the medical record for patients with diabetic retinopathy.
保险计费索赔数据库是眼科领域中一个不断发展的科学研究领域。验证糖尿病视网膜病变治疗过程中使用的计费索赔代码的准确性，是全面理解这类研究的基础数据及后续结果的必要前提。
确定糖尿病视网膜病变治疗中使用的诊断、程序和治疗计费代码的准确性。
设计、设置和参与者：这项回顾性病历审查在3家临床机构（1家学术机构和2家私立机构）进行。2011年至2013年期间，这些机构诊治了有保险的糖尿病视网膜病变患者。然后，对每位患者2年的每次就诊记录进行了两次审查，一次审查计费数据，另一次审查病历数据。2015年10月至2016年7月收集并分析数据。
每个感兴趣代码的阳性预测值（PPV）和阴性预测值（NPV）。敏感性和特异性为次要结局。
来自11位医生的146例患者（平均[标准差]年龄为60.3[12.5]岁）在2个日历年里接受了1072次会诊审查。纳入的患者中，49.3%为女性（n = 72），48.6%为白人（n = 71），37.0%为黑人（n = 54），18.5%患有1型糖尿病，平均（标准差）糖化血红蛋白水平为7.7%（1.8）（n = 27）。几乎所有经常使用的感兴趣代码的PPV（范围为89.5%-100%）和NPV（88.6%-100%）都很高，包括玻璃体内注射、局部激光、全视网膜光凝、手术部位、雷珠单抗、贝伐单抗、眼底照片、荧光素血管造影和光学相干断层扫描的计费代码。使用频率较低（<20例）但PPV（均为100%）和NPV（99.7%-100%）仍然较高的代码是阿柏西普、曲安奈德和地塞米松植入物的代码。仅发现使用频率较低的B超扫描（PPV为69.6%）和球后注射（PPV为100%；NPV为99.7%，但敏感性仅为40%）的代码准确性存疑。除球后注射（40%）外，所有代码的敏感性（范围为87.6%-100%）和特异性（范围为97.2%-100%）也都很高。
这些数据表明，从保险计费索赔中得出的诊断、程序和治疗代码准确反映了糖尿病视网膜病变患者的病历。
