Methods in Assessing Non-Traumatic Dental Care in Emergency Departments



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Diagnosis-Procedure Codes Investigated


ICD-9 diagnosis codes used in analysis provide for direct comparisons between research studies. There are definite variations in the strategies of codes used by researchers. One major difference is whether they are interested in any dentally related condition or procedure, or if they are interested in a subset of dental conditions/procedures. A fairly exhaustive range of dental/oral related ICD 9 codes and their descriptions are presented in Appendix 5.

Some investigators set out to investigate any dental care sought in non-dental settings [e.g. Cohen et al.(25), DeLia et al.(93), Hom et al.(45), Shortridge and Moore(57)], often using the entire range of ICD-9 codes 520-529.9. In their analysis of dental care seeking in medical settings by Oregon Medicaid enrollees, Wallace et al. used codes 521.00 – 523.99, 525.30 – 525.39, 525.90 – 525.99, 873.63, and 873.73 to define services for dental problems.(56) In one analysis of NAMCH data, Wall was interested in ED dental visits related to disorders of the teeth and jaws, using ICD-9 codes 520.00 – 526.99.(29) In another analysis of NEDS data, Wall and Vujicic expanded this definition to include ambulatory care sensitive dental conditions, using codes 520.0 – 526.9, 528.0 – 528.9, 784.92, V523, V534, V585, and V722.(24) Some investigators use an even broader range of dental/oral related codes to capture ED visits related to other oral problems such as oral injuries/trauma or TMJ problems. Hong et al. used codes for dental caries (520.1), other dental disease unspecified (521.2, 521.3, 522.0 – 522.9, 523, 525 – 529), TMJ disorders (524.6, 830.0 – 830.1, 848.1), and injuries to dentofacial structures (873.51, 873.53, 873.54, 873.63 – 873.69).(82) Neely et al. likewise used a wide range of ICD-9 codes that related to any condition of the teeth, mouth, jaw, face, or neck.(68)

Another major category includes researchers who are interested in access to non-dental settings for specific dental conditions that are readily prevented or definitively treated through regular traditional dental care, using a subset of dental codes. This latter category represents the more specific investigation of preventable dental conditions (NTDCs) addressed in EDs, which is the primary focus of this report.

Within this category many of the previously mentioned studies limited their research to specific ICD codes determined to identify NTDCs. Though often similar, the exact set of codes employed in analyses was often not the same. McCormick et al. used ICD-9 codes 520 to 526.99.(67) In defining NTDCs, Sun et al. used codes 520.0 – 520.9, 521.00 - 521.09, 522.0 - 522.9, 523.00 - 523.9, and 525.0 – 525.9.(44) Allareddy et al. used codes 521.00 - 521.09, 522.0 - 522.9, 523.00 - 523.9, 528.3.(21, 22) Anderson et al. used codes 521, 522, 523, 525, and 528.(87) Of note in the case of using code 525 is that 525.11 is for “loss of teeth due to trauma.” Unfortunately, some reports don’t include the specific codes used when indicating that they limited investigation to NTDCs.(72) Okunseri et al. used ICD-9 codes 521 – 521.9, 522 – 522.9, 523 – 523.9, 525.3, 525.9 in identifying NTDCs in several of their analyses of NHAMC survey data.(32-34, 36) Okunseri et al. added code 873.63 in identifying NTDCs in their Wisconsin Medicaid data study of NTDC treatment in EDs and physician offices.(50) Nakao et al. in identifying NTDCs for their study used the same codes as the Okunseri Medicaid data study (codes 521 – 521.9, 522 – 522.9, 523 – 523.9, 525.3, 525.9, 873.63).(40) Of note is that both authors describe code 873.63 as “internal structures of mouth, without broken tooth,” but looking up the ICD-9 code revealed a definition of “broken or fractured tooth due to trauma without mention of complications.” Okunseri et al., in another report of ED treatment for NTDCs, defined NTDCs with a much broader definition including codes 520.0 - 521.9, 522.0 – 522.9, 523.0 – 523.9, 524.0 – 524.9, 525.0 - 525.6, 525.9, 526.0 -526.9, 527.0 – 527.0, 528.0 – 528.9, 529.0 – 529.9, and 873.63.(35) Singhal et al. defined dental visits to the ED using ICD-9 codes 521.00-521.99, 522.00-522.99, 523.00-523.99, 525.00-525.99, 528.00-528.99.(55) Though the investigators state that they were identifying visits with a “primary diagnosis of dental disease,” further explanation in the appendix shows they were focusing on non-traumatic dental conditions ideally seen in a dental office, but presenting at the ED likely due to lack of access to dental care. While Shortridge and Moore used codes 520-529.9 in their analysis of 2005 SEDD data from three states, they also created a subset of dental diagnosis codes considered preventable or severe, but didn’t provide the specific codes included in these subsets.(57)



Investigators interested in more specific diagnoses make use of a subset of NTDC related ICD-9 codes. Hayes et al. used codes related to dental infections (521.0 to 523.9 and 525.0 to 525.9) to identify patients presenting to EDs with dental infections in their study comparing ED patient receiving medications at ED discharge to those receiving only prescriptions.(74) Naliah et al. chose to focus specifically on caries related ED visits and only used ICD-9 codes 521.00 – 521.09.(23) Walker et al. also wanted to focus on dental caries related diagnoses, but chose to use codes 521.0 – 521.09, 522.0, 522.1, 525.13, 525.63, 525.64, and 527.3 (abscess of salivary gland).(37) Study authors and ICD-9 codes used in their research are summarized in Table 13.

Table 13: Authors and ICD-9 Codes Studied

Authors

Local/Subpopulation Target Population

Cohen et al.(25)

520-529.9

DeLia et al.(93)

520-529.9

Hom et al.(45)

520-529.9

Shortridge and Moore(57)

520-529.9

Wallace et al.(56)

521.00 – 523.99, 525.30 – 525.39, 525.90 – 525.99, 873.63, 873.73

Wall(29)

520.00 – 526.99

Wall and Vujicic(24)

520.0 – 526.9, 528.0 – 528.9, 784.92, V523, V534, V585, V722

Hong et al.(82)

520.1, 521.2, 521.3, 522.0 – 522.9, 523, 525 – 529, 524.6, 830.0 – 830.1, 848.1, 873.51, 873.53, 873.54, 873.63 – 873.69

McCormick et al.(67)

520-526.99

Sun et al.(44)

520.0 – 520.9, 521.00 - 521.09, 522.0 - 522.9, 523.00 - 523.9, 525.0 – 525.9

Allareddy et al.(21, 22)

521.00 - 521.09, 522.0 - 522.9, 523.00 - 523.9, 528.3

Anderson et al.(87)

521, 522, 523, 525, and 528.

Okunseri et al.(32-34, 36)

521 – 521.9, 522 – 522.9, 523 – 523.9, 525.3, 525.9

Okunseri et al.(50)

521 – 521.9, 522 – 522.9, 523 – 523.9, 525.3, 525.9, 873.63

Nakao et al.(40)

521 – 521.9, 522 – 522.9, 523 – 523.9, 525.3, 525.9, 873.63

Okunseri et al.(35)

520.0 - 521.9, 522.0 – 522.9, 523.0 – 523.9, 524.0 – 524.9, 525.0 - 525.6, 525.9, 526.0 -526.9, 527.0 – 527.0, 528.0 – 528.9, 529.0 – 529.9, 873.63

Singhal et al.(55)

521.00-521.99, 522.00-522.99, 523.00-523.99, 525.00-525.99, 528.00-528.99

Hayes et al.(74)

521.0 to 523.9, 525.0 to 525.9

Naliah et al.(23)

521.00 – 521.09

Walker et al.(37)

521.0 – 521.09, 522.0, 522.1, 525.13, 525.63, 525.64, 527.3

The NHAMCS national probability survey of U. S. hospital EDs has its own set of codes for a “reason for visit” variable that was used to identify ED visits for dental care. Lee et al. used codes 1500.0 (symptoms of teeth and gums), 1500.1 (toothache), 1500.2 (gum pain), and 1500.3 (bleeding gums) to identify ED visits for dental care for this “reason for visit” variable, in part because of problems in physician use of ICD-9 dental codes. Lewis used NHAMCS data to determine national rates and predictors of ED dental use in one study,(30) and then reported comparisons, trends, and predictors of ED dental use by young adults compared to other ED users,(31) focusing on codes 1500.0 and 1500.1.


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