Volume 27, Issue 4 (1-2025)
jha 2025, 27(4): 1-14 |
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Khorrami F, Alishan Karami N, Mohammad Hosein H, Kamali Chahooei M, Alipour J. Coding accuracy and completeness of documentation of medical procedures for
injuries, poisonings, and certain other consequences of external causes in ICHI
and ICD-9-CM at Shahid Mohammadi Hospital in Bandar Abbas, Iran. jha 2025; 27 (4) :1-14
URL: http://jha.iums.ac.ir/article-1-4573-en.html
URL: http://jha.iums.ac.ir/article-1-4573-en.html
Farid Khorrami1 
, Nader Alishan Karami1 , Hayavi-Haghighi Mohammad Hosein1 , Mina Kamali Chahooei1 , Jahanpour Alipour2
, Nader Alishan Karami1 , Hayavi-Haghighi Mohammad Hosein1 , Mina Kamali Chahooei1 , Jahanpour Alipour2
1- Department of Health Information Technology, School of Paramedicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
2- Health Human Resources Research Center, Department of Health Information Management, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.. ,jahanpour.alipour@gmail.com
2- Health Human Resources Research Center, Department of Health Information Management, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.. ,
Abstract: (90 Views)
Introduction: High-quality documentation is a prerequisite for accurate coding. This study aims to assess the quality of documentation and accuracy of coding medical procedures with the ICHI and ICD-9-CM.
Methods: A descriptive cross-sectional study was conducted in 2023. A total of 382 medical records related to injuries, poisonings, and certain other consequences of external causes were selected using Cochran's formula. The completeness of documentation and the accuracy of coding medical procedures with ICD-9-CM and the documentation completeness required for ICD-9-CM and ICHI, were evaluated using re-coding and a checklist. Data were analyzed using descriptive statistics (frequency and percentage) using SPSS software.
Results: Of the 382 medical records reviewed, 77% had at least one type of major or minor ICD-9-CM coding error. Among the inaccurate records, 81% had only major errors (errors in the first two digits), 6% had only minor errors (errors in the last two digits), and 13% had both types of errors. Furthermore, 42% of the codes were accurate. Documentation completeness for ICD-9-CM was 100%. However, 168 and 42 medical records lacked documentation for the Means and Target components, respectively, required for ICHI coding.
Conclusion: While documentation of procedures for ICD-9-CM coding was highly favorable, the accuracy of coding was low. Half of the cases lacked the necessary documentation for ICHI coding. Therefore, it is essential to develop written documentation guidelines based on ICHI, train coders, provide regular feedback on documentation quality, utilize automated coding support tools, and conduct continuous audits of coding quality.
Methods: A descriptive cross-sectional study was conducted in 2023. A total of 382 medical records related to injuries, poisonings, and certain other consequences of external causes were selected using Cochran's formula. The completeness of documentation and the accuracy of coding medical procedures with ICD-9-CM and the documentation completeness required for ICD-9-CM and ICHI, were evaluated using re-coding and a checklist. Data were analyzed using descriptive statistics (frequency and percentage) using SPSS software.
Results: Of the 382 medical records reviewed, 77% had at least one type of major or minor ICD-9-CM coding error. Among the inaccurate records, 81% had only major errors (errors in the first two digits), 6% had only minor errors (errors in the last two digits), and 13% had both types of errors. Furthermore, 42% of the codes were accurate. Documentation completeness for ICD-9-CM was 100%. However, 168 and 42 medical records lacked documentation for the Means and Target components, respectively, required for ICHI coding.
Conclusion: While documentation of procedures for ICD-9-CM coding was highly favorable, the accuracy of coding was low. Half of the cases lacked the necessary documentation for ICHI coding. Therefore, it is essential to develop written documentation guidelines based on ICHI, train coders, provide regular feedback on documentation quality, utilize automated coding support tools, and conduct continuous audits of coding quality.
Type of Study: Research |
Subject:
Health Information Technology
Received: 2024/10/28 | Accepted: 2025/06/8 | Published: 2025/06/19
Received: 2024/10/28 | Accepted: 2025/06/8 | Published: 2025/06/19
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