title: Evaluation of factors influencing accuracy of principal procedure coding based on ICD-9-CM: an Iranian study.
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 chi(2) 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.
authors.affiliation: Kashan University of Medical Sciences in Kashan, Iran.
authors.forename: Mehrdad
authors.initials: M
authors.lastname: Farzandipour
authors.forename: Abbas
authors.initials: A
authors.lastname: Sheikhtaheri
mesh_terms: D002965:Classification; D005568:Forms and Records Control / Q000706:statistics & numerical data; D006739:Hospital Administration / Q000706:statistics & numerical data*; D006801:Humans; D038801:International Classification of Diseases / Q000706:statistics & numerical data*; D007492:Iran; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D015203:Reproducibility of Results