title: Discordance between physicians and coders in assignment of diagnoses.
abstract: OBJECTIVE
  To measure concordance between physicians and medical record coders in their assignment of diagnoses.
  
  
  METHODS
  Prospective cohort series.
  
  
  METHODS
  Five hundred and fifty-bed, tertiary-care, university teaching hospital. Study participants. In-patients who were discharged from either the Cardiac Sciences Program (n=125), the Renal Program (n=43), or the HIV-AIDS Program (n=25) during the period May 18-July 1, 1995.
  
  
  METHODS
  None.
  
  
  METHODS
  Physicians and coders assigned diagnoses for individual in-patients based on their independent interpretations of the patient chart and discharge summary sheet. All assigned diagnoses were coded using the ICD-9-CM classification system. Concordance was measured for the most responsible diagnosis and for all assigned diagnoses. Difference in calculated resource intensity weights based on physicians' and coders' assignment of diagnoses was also calculated.
  
  
  RESULTS
  Concordance rates for the most responsible diagnosis in each program were: Cardiac Sciences [27%; 95% confidence interval (CI)=20-36%], Renal Program (35%; 95% CI=21-53%), and HIV-AIDS Program (20%; 95% CI, 6-41%). Concordance rates for all diagnoses per chart were similar: Cardiac Sciences (20%; 95% CI, 14-25%), Renal Program (25%; 95% CI, 20-33%), and HIV-AIDS Program (29%; 95% CI, 25-44%). Resource intensity weights assigned by coders for the Cardiac Sciences and HIV-AIDS Program were significantly higher than those assigned by the physicians.
authors.affiliation: Health Information Science, University of Victoria, Canada.
authors.forename: P
authors.initials: P
authors.lastname: Yao
authors.forename: B R
authors.initials: BR
authors.lastname: Wiggs
authors.forename: C
authors.initials: C
authors.lastname: Gregor
authors.forename: R
authors.initials: R
authors.lastname: Sigurnjak
authors.forename: P
authors.initials: P
authors.lastname: Dodek
mesh_terms: D000043:Abstracting and Indexing / Q000592:standards*; D001955:British Columbia; D015331:Cohort Studies; D003953:Diagnosis-Related Groups / Q000145:classification*; D006785:Hospitals, University; D006801:Humans; D008492:Medical Informatics Computing / Q000592:standards*; D008497:Medical Record Administrators; D008499:Medical Records / Q000145:classification* / Q000592:standards; D010820:Physicians; D011446:Prospective Studies; D011786:Quality Control