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- Title
Evaluation of Factors Influencing Accuracy of Principal Procedure Coding Based on ICD-9-CM: An Iranian.
- Authors
Farzandipour, Mehrdad; Sheikhtaheri, Abbas
- Abstract
To evaluate the accuracy of procedural coding and the factors that influence it, 246 records were randomly selected from four teaching hospitals in Kashan, Iran. "Recodes" were assigned blindly and then compared to the original codes. Furthermore, the coders' professional behaviors were carefully observed during the coding process. Coding errors were classified as major or minor. The relations between coding accuracy and possible effective factors were analyzed by X2 or Fisher exact tests as well as the odds ratio (OR) and the 95 percent confidence interval for the OR. The results showed that using a tabular index for rechecking codes reduces errors (83 percent vs. 72 percent accuracy). Further, more thorough documentation by the clinician positively affected coding accuracy, though this relation was not significant. Readability of records decreased errors overall (p = .003), including major ones (p = .012). Moreover, records with no abbreviations had fewer major errors (p = .021). In conclusion, not using abbreviations, ensuring more readable documentation, and paying more attention to available information increased coding accuracy and the quality of procedure databases.
- Subjects
KASHAN (Iran); IRAN; CONFIDENCE intervals; TEACHING hospitals; DATABASE management; DOCUMENTATION; MEDICAL personnel; CODING theory; ELECTRONIC data processing; MEDICAL informatics
- Publication
Perspectives in Health Information Management, 2009, Vol 6, Issue 3, p1
- ISSN
1559-4122
- Publication type
Article