Measuring diagnoses: ICD code accuracy
Measuring diagnoses: ICD code accuracy
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DOI：
10.1111/j.1475-6773.2005.00444.x
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发表时间：
2005-10-01
影响因子：
3.4
通讯作者：
Ashton, CM
中科院分区：
文献类型：
--
作者：
O'Malley, KJ;Cook, KF;Ashton, CM
目标。检查所描述的住院患者国际疾病分类(ICD)编码过程中每一步的潜在错误来源。数据来源/研究设置。ICD疾病代码的使用已经从为统计目的对发病率和死亡率信息进行分类扩展到在研究、卫生保健政策和卫生保健财务方面的各种应用。通过描述ICD编码的简要历史，详细说明分配代码的过程，确定在该过程中可能引入错误的地方，以及审查代码准确性的方法，我们帮助代码用户更系统地评估其特定应用的代码准确性。我们总结了从患者入院到诊断代码分配的住院ICD诊断编码过程。我们检查每一步的潜在错误来源，并为代码用户提供一个系统地评估代码准确性的工具。“患者轨迹”的主要误差来源包括入院时的信息量和质量、患者和提供者之间的沟通、临床医生对疾病的知识和经验，以及临床医生对细节的关注。主要的错误来源包括电子记录和书面记录的差异、编码员的培训和经验、设施质量控制的努力，以及错误说明、拆分和升级等无意和故意的编码员错误。通过明确规定代码分配过程并提高他们对潜在误差源的认识，代码用户可以更好地评估代码针对其特定情况的适用性和局限性。然后，可以以最适当的方式使用ICD代码。
Objective. To examine potential sources of errors at each step of the described inpatient International Classification of Diseases (ICD) coding process.Data Sources/Study Setting. The use of disease codes from the ICD has expanded from classifying morbidity and mortality information for statistical purposes to diverse sets of applications in research, health care policy, and health care finance. By describing a brief history of ICD coding, detailing the process for assigning codes, identifying where errors can be introduced into the process, and reviewing methods for examining code accuracy, we help code users more systematically evaluate code accuracy for their particular applications.Study Design/Methods. We summarize the inpatient ICD diagnostic coding process from patient admission to diagnostic code assignment. We examine potential sources of errors at each step and offer code users a tool for systematically evaluating code accuracy.Principle Findings. Main error sources along the "patient trajectory" include amount and quality of information at admission, communication among patients and providers, the clinician's knowledge and experience with the illness, and the clinician's attention to detail. Main error sources along the "paper trail" include variance in the electronic and written records, coder training and experience, facility quality-control efforts, and unintentional and intentional coder errors, such as misspecification, unbundling, and upcoding.Conclusions. By clearly specifying the code assignment process and heightening their awareness of potential error sources, code users can better evaluate the applicability and limitations of codes for their particular situations. ICD codes can then be used in the most appropriate ways.