صحت كدگذاري اقدامات درماني بر اساس ICD9CM

Accuracy of Procedure Coding Based on ICD9CM*

Introduction: Using hospital databases is extremely depended on an accurate classification that is based on clinical coding. We aimed to determine the validity of procedural coding in teaching hospitals. Methods: In this cross-sectional study, 246 medical files from Kashan hospitals was selected randomly, in 2007.Information regarding procedures, codersʹ information, and documentation principles were recorded using a valid checklist. The procedures were re-corded. Accuracy of coding was determined by agreement between original codes and recoded ones. We analyzed the data using SPSS through fisher test, OR, and CI 95% for OR. Results: There were 46 (18.7%) errors in procedure coding. Using the coding book significantly accompanied with more code errors; however, there were fewer errors in records which coders checked codes with tabular index. Documenting more information decreases the errors (not significant). There were fewer errors in readable records. In addition, clear abbreviations reduced errors. Conclusion: We can trust on procedure databases. Better documenting the procedure details and factors related to coders could improve the quality of procedure coding and databases. Keywords: Classifications; Coding; Files; Medical Records. Type of article: Original Article