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.. ,
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Table 2. Ranking of documentation deficiencies in medical records based on the details required ICD-9-CM and ICHI coding
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Introduction
High-quality data collection and coding of diagnoses and procedures in patient medical records are necessary for the accuracy of clinical research, epidemiological analyses, quality audits of services and procedures, resource allocation, policy-making, planning, and healthcare decision-making at local, national, and international levels [1-3]. To reduce coding errors, minimize insurance claim rejections, and maximize reimbursement, medical records must be properly documented [4]. Lack of coder training, particularly when using new versions of a classification system, inadequate audit mechanisms and feedback to coders [5-7], illegible or incomplete documentation, limited interaction between coders and clinical specialists [5-10], and lack of access to necessary coding resources and tools are among the factors that lead to poor-quality clinical documentation and coding [6, 10].
Equitable utilization of healthcare services, quality management, access to services, and ultimately health equity requires comprehensive information on health interventions. To cover the full range of healthcare interventions, the World Health Organization (WHO) developed the international classification of health interventions (ICHI). This system provides a standard framework and terminology for collecting, integrating, evaluating, and comparing data on health interventions, making it easier to describe and obtain information related to health promotion and prevention [11, 12]. Volume 3 of the ninth edition of the international classification of diseases - clinical modifications (ICD-9-CM) is not comprehensive enough to cover all health interventions; it primarily covers surgical operations and includes only a limited range of non-surgical procedures [13]. On the other hand, ICHI's core terminology and structure facilitate detailed coding of various health interventions [14].
The ICHI classification system captures diagnostic, medical, surgical, mental health, primary care, ancillary healthcare, functional support, rehabilitation, traditional medicine, and public health interventions. For clinical and statistical applications, ICHI offers a standardized tool for the analysis and reporting of health interventions [11, 14]. In Iran, medical procedures are currently coded using ICD-9-CM volume 3 [5]. Given the limited scope of the current procedure coding system in Iran, transitioning to a comprehensive international standard like ICHI is necessary to classify all types of interventions. This study aims to assess the accuracy of procedure coding based on the ICD-9-CM classification system and evaluate the quality of medical record documentation for procedure coding based on both the ICHI and ICD-9-CM classification systems.
Methods
This descriptive, cross-sectional study was conducted in 2023. The study population included 11,638 patient records, from Shahid Mohammadi Hospital in Bandar Abbas, related to patients admitted with various injuries, poisonings, and other external causes. The interventions had already been coded by hospital coders using ICD-9-CM. The procedures related to these diagnoses were selected due to the availability of a sufficient number of records and the routine assignment of procedure codes for this category of conditions. Given the known population size, Cochran's formula (n= NZ2pq/Nd2 + Z2pq) with d=0.05, p=q=0.5, and Z=1.96 was used to calculate a sample size of 382 medical records, selected using simple random sampling.
This study was conducted in two phases. In the first phase, medical records coded by the hospital coders using ICD-9-CM were independently re-coded by two evaluators using the same classification system. Evaluators were selected based on having a BSc of health information technology and at least three years of practical hospital coding experience. The codes assigned by the evaluators were then compared. In cases of discrepancies between the two evaluators, records were re-coded by a third evaluator, a university faculty member with a PhD and over ten years of theoretical and practical coding experience, whose codes were considered the correct codes. Subsequently, the evaluators’ final codes were compared with those of the hospital coders to assess accuracy and identify coding errors based on ICD-9-CM. A checklist was used to assess code accuracy and categorize error types. This checklist recorded whether the codes were accurate and identified major or minor coding errors. In this study, major errors were defined as either a missing code or errors in coding the nature or site of interventions (errors in the first two digits), while minor errors referred to errors in the coding of the approach, instrument, or direction of the procedure (errors in the digits after the decimal point) [15].
In the second phase, the details of each procedure code related to injuries, poisonings, or other external causes were determined using the ICD-9-CM and ICHI. Based on this, a two-part checklist was developed to identify documentation deficiencies in medical records. The first section encompassed ICD-9-CM details including site approach, direction, or instrument of a procedure. The second section contained the details of medical procedures based on ICHI including Target, Action, and Means. To validate the tool, the checklist was reviewed by five faculty members with a PhD degree in health information management; following their feedback, it was approved. Documentation deficiencies were assessed using the ranking criteria proposed in a study [16]. The ranking system was as follows: score 1: documentation does not reflect the codes or related descriptions at all (codes, details, and descriptions are missing); score 2: documentation largely does not reflect the codes and related descriptions (main details are missing); score 3: documentation partially reflects the codes and related descriptions (some missing details ); score 4: documentation almost fully reflects the codes and related descriptions (a few details are missing) and score 5: documentation fully reflects all codes, details, and related descriptions. Data were analyzed using descriptive statistics, including frequency, and percentage.
Results
Coding accuracy
In the 382 reviewed records, a total of 745 procedure codes were assigned using ICD-9-CM. Seventy-seven percent (295 records) had at least one type of major or minor ICD-9-CM coding error, with 81% (240 records) of these inaccurate records containing only major errors, 6% (17 records) only minor errors, and 13% (38 records) having both types of errors. The first and second evaluators assigned 948 and 962 procedure codes, respectively. Inter-rate reliability between evaluators was 98.6%. After consultation with the third evaluator, the final number of codes was determined to be 948. Of the total number of ICD-9-CM codes assigned, 51 % (479 codes) were accurate.
High-quality data collection and coding of diagnoses and procedures in patient medical records are necessary for the accuracy of clinical research, epidemiological analyses, quality audits of services and procedures, resource allocation, policy-making, planning, and healthcare decision-making at local, national, and international levels [1-3]. To reduce coding errors, minimize insurance claim rejections, and maximize reimbursement, medical records must be properly documented [4]. Lack of coder training, particularly when using new versions of a classification system, inadequate audit mechanisms and feedback to coders [5-7], illegible or incomplete documentation, limited interaction between coders and clinical specialists [5-10], and lack of access to necessary coding resources and tools are among the factors that lead to poor-quality clinical documentation and coding [6, 10].
Equitable utilization of healthcare services, quality management, access to services, and ultimately health equity requires comprehensive information on health interventions. To cover the full range of healthcare interventions, the World Health Organization (WHO) developed the international classification of health interventions (ICHI). This system provides a standard framework and terminology for collecting, integrating, evaluating, and comparing data on health interventions, making it easier to describe and obtain information related to health promotion and prevention [11, 12]. Volume 3 of the ninth edition of the international classification of diseases - clinical modifications (ICD-9-CM) is not comprehensive enough to cover all health interventions; it primarily covers surgical operations and includes only a limited range of non-surgical procedures [13]. On the other hand, ICHI's core terminology and structure facilitate detailed coding of various health interventions [14].
The ICHI classification system captures diagnostic, medical, surgical, mental health, primary care, ancillary healthcare, functional support, rehabilitation, traditional medicine, and public health interventions. For clinical and statistical applications, ICHI offers a standardized tool for the analysis and reporting of health interventions [11, 14]. In Iran, medical procedures are currently coded using ICD-9-CM volume 3 [5]. Given the limited scope of the current procedure coding system in Iran, transitioning to a comprehensive international standard like ICHI is necessary to classify all types of interventions. This study aims to assess the accuracy of procedure coding based on the ICD-9-CM classification system and evaluate the quality of medical record documentation for procedure coding based on both the ICHI and ICD-9-CM classification systems.
Methods
This descriptive, cross-sectional study was conducted in 2023. The study population included 11,638 patient records, from Shahid Mohammadi Hospital in Bandar Abbas, related to patients admitted with various injuries, poisonings, and other external causes. The interventions had already been coded by hospital coders using ICD-9-CM. The procedures related to these diagnoses were selected due to the availability of a sufficient number of records and the routine assignment of procedure codes for this category of conditions. Given the known population size, Cochran's formula (n= NZ2pq/Nd2 + Z2pq) with d=0.05, p=q=0.5, and Z=1.96 was used to calculate a sample size of 382 medical records, selected using simple random sampling.
This study was conducted in two phases. In the first phase, medical records coded by the hospital coders using ICD-9-CM were independently re-coded by two evaluators using the same classification system. Evaluators were selected based on having a BSc of health information technology and at least three years of practical hospital coding experience. The codes assigned by the evaluators were then compared. In cases of discrepancies between the two evaluators, records were re-coded by a third evaluator, a university faculty member with a PhD and over ten years of theoretical and practical coding experience, whose codes were considered the correct codes. Subsequently, the evaluators’ final codes were compared with those of the hospital coders to assess accuracy and identify coding errors based on ICD-9-CM. A checklist was used to assess code accuracy and categorize error types. This checklist recorded whether the codes were accurate and identified major or minor coding errors. In this study, major errors were defined as either a missing code or errors in coding the nature or site of interventions (errors in the first two digits), while minor errors referred to errors in the coding of the approach, instrument, or direction of the procedure (errors in the digits after the decimal point) [15].
In the second phase, the details of each procedure code related to injuries, poisonings, or other external causes were determined using the ICD-9-CM and ICHI. Based on this, a two-part checklist was developed to identify documentation deficiencies in medical records. The first section encompassed ICD-9-CM details including site approach, direction, or instrument of a procedure. The second section contained the details of medical procedures based on ICHI including Target, Action, and Means. To validate the tool, the checklist was reviewed by five faculty members with a PhD degree in health information management; following their feedback, it was approved. Documentation deficiencies were assessed using the ranking criteria proposed in a study [16]. The ranking system was as follows: score 1: documentation does not reflect the codes or related descriptions at all (codes, details, and descriptions are missing); score 2: documentation largely does not reflect the codes and related descriptions (main details are missing); score 3: documentation partially reflects the codes and related descriptions (some missing details ); score 4: documentation almost fully reflects the codes and related descriptions (a few details are missing) and score 5: documentation fully reflects all codes, details, and related descriptions. Data were analyzed using descriptive statistics, including frequency, and percentage.
Results
Coding accuracy
In the 382 reviewed records, a total of 745 procedure codes were assigned using ICD-9-CM. Seventy-seven percent (295 records) had at least one type of major or minor ICD-9-CM coding error, with 81% (240 records) of these inaccurate records containing only major errors, 6% (17 records) only minor errors, and 13% (38 records) having both types of errors. The first and second evaluators assigned 948 and 962 procedure codes, respectively. Inter-rate reliability between evaluators was 98.6%. After consultation with the third evaluator, the final number of codes was determined to be 948. Of the total number of ICD-9-CM codes assigned, 51 % (479 codes) were accurate.
Table 1. Accuracy status and type of coding error based on ICD-9-CM Volume 3 (Total codes reviewed: N = 948)
| Title of the chapter | Blocks | Accuracy N (%) |
Type of errors N (%) |
||
| True | False | Major | Minor | ||
| Procedures and interventions, not elsewhere classified | 00 | 0 | 1(0) | 1(0) | 0 |
| Operations on the nervous system | 01-05 | 59(12) | 7(1) | 7(2) | 0 |
| Operations on the endocrine system | 06-07 | 0 | 1(0) | 1 (0) | 0 |
| Operations on the Eye | 08-17 | 3(1) | 3(1) | 3 (1) | 0 |
| Operations on the Ear | 18-20 | 0 | 0 | 0 (0) | 0 |
| Operations on the nose, mouth, and throat | 21-29 | 8(2) | 3(1) | 3 (1) | 0 |
| Operations on the respiratory system | 30-34 | 11(2) | 3(2) | 2(0) | 1 (2) |
| Operations on the cardiovascular system | 35-39 | 20(4) | 4(1) | 4(1) | 0 |
| Operations on the hemic and lymphatic system | 40-41 | 3(1) | 0 | 0 | 0 |
| Operations on the digestive system | 42-54 | 4(1) | 4(1) | 4(1) | 0 |
| Operations on the urinary system | 55-59 | 1(0) | 0 | 0 | 0 |
| Operations on male genital organs | 60-64 | 1(0) | 0 | 0 | 0 |
| Operations on female genital organs | 65-71 | 0 | 0 | 0 | 0 |
| Obstetric procedures | 72-75 | 0 | 0 | 0 | 0 |
| Operations on the musculoskeletal system | 76-84 | 183(38) | 241(51) | 213(52) | 28(46) |
| Operations on the integumentary system | 85-86 | 156(33) | 83 (18) | 51 (13) | 32(52) |
| Miscellaneous diagnostic and therapeutic procedures | 87-99 | 30(6) | 119(25) | 119(29) | 0 |
| Total | 479(51) | 469(49) | 408 (87) | 61 (13) | |
The major errors occurred primarily in musculoskeletal system procedures (51%), miscellaneous diagnostic and therapeutic procedures (25%), and operations on the integumentary system (18%). The primary major errors were related to operations on the musculoskeletal system (52%), miscellaneous diagnostic and therapeutic procedures (29%), and operations on integumentary system (13%). The main minor errors were related to operations on integumentary system (52%) and musculoskeletal system (46%) (Table 1).
Accuracy and type of ICD-9-CM coding error
Eighty-seven percent of the errors were major, while 13% were minor. Major coding errors included failure to assign a code (43%), incorrect selection of the nature of the procedure (18%), site of the procedure (21%), and upcoding (5%). Minor errors included incorrect selection of “approach” (10%) and “instrument” (3%), with no minor errors related to “direction”.
Documentation deficiencies
According to the findings, 100% of the required documentation for ICD-9-CM coding, including site, approach, and instrument, was documented in the medical records. Based on the ICHI, documentation deficiencies were mostly related to missing details regarding the Means (44%) and the Target (12%). Documentation completeness for ICD-9-CM coding was 100%, whereas for ICHI coding, it was 51%.
Accuracy and type of ICD-9-CM coding error
Eighty-seven percent of the errors were major, while 13% were minor. Major coding errors included failure to assign a code (43%), incorrect selection of the nature of the procedure (18%), site of the procedure (21%), and upcoding (5%). Minor errors included incorrect selection of “approach” (10%) and “instrument” (3%), with no minor errors related to “direction”.
Documentation deficiencies
According to the findings, 100% of the required documentation for ICD-9-CM coding, including site, approach, and instrument, was documented in the medical records. Based on the ICHI, documentation deficiencies were mostly related to missing details regarding the Means (44%) and the Target (12%). Documentation completeness for ICD-9-CM coding was 100%, whereas for ICHI coding, it was 51%.
Table 2. Ranking of documentation deficiencies in medical records based on the details required ICD-9-CM and ICHI coding
| Score | ICD-9-CM | ICHI | ||
| Frequency | Percent | Frequency | Percent | |
| 5 | 382 | 100 | 194 | 51 |
| 4 | 0 | 0 | 166 | 43 |
| 3 | 0 | 0 | 0 | 0 |
| 2 | 0 | 0 | 0 | 0 |
| 1 | 0 | 0 | 22 | 6 |
Discussion
Procedures were classified using ICD-9-CM by hospital coders and independent evaluators. The study found that only 51% of the procedure codes assigned using ICD-9-CM were accurate. Errors in coded procedures at the level of nature and site (major errors) accounted for 87%, while errors related to approach, means, and direction (minor errors) were 13%, respectively. In Iran, Ahmadi et al. [17] reported an average accuracy rate of 89.5% for coding procedures. Additionally, Farzandipour and Sheikhtaheri [15] reported overall coding accuracy of 81%, with 97% accuracy for the primary two-digit level, and 81% for two digits after the decimal point. In England, Burns et al. [1] reported an average accuracy rate for coding medical procedures as 84%. In Malaysia, Zafirah et al. [18] reported the accuracy of coding as 51% for primary procedures and 58% for secondary procedures, which significantly impacted the implementation of DRG and hospital income. In the United States, Balla et al. [19] stated that the overall accuracy of surgical residents in coding medical procedures was 82.52%. Moreover, Beck et al. [20] reported the accuracy of coding hip fracture surgical procedures as 66%. In South Africa, Britton et al. [21] mentioned a 35% accuracy rate in coding clinical procedures and reported the negative impact of coding errors on hospital revenue. The results of our study were lower than those reported in studies [1, 15, 17, 19-20], higher than [21] and similar to study [18]. Additionally, the ICD-9-CM classification was published in 1979 and has been discontinued in many countries, with limited studies in the last decade evaluating the accuracy of procedure coding using ICD-9-CM. Most studies have focused on evaluating the impact of coding quality on reimbursement systems and hospital income [18, 20-22].
The major reason for the high rate of coding errors identified in this study was the coders' exclusive reliance on admission and discharge summary sheet, unit summary sheet, and operation report sheet. However, billing forms contain more detailed and comprehensive information about the procedures performed. Another reason for coding errors was the omission of non-surgical procedures such as gastric lavage, blood transfusion, intubation, and catheterization. In other words, the study found that coders focused only on surgical procedures, whereas all procedures, both surgical and non-surgical, should be coded. Additionally, inaccurate application of coding rules, failure to consult the alphabetic index, use of outdated coding books, incomplete medical records, and the complexity of coding process were identified as contributing factors to coding errors.
Based on the findings, the inter-rater reliability between the first and second evaluators for ICD-9-CM procedure coding was 98.6%. Daneshvar et al. [23] in Canada reported a 96% reliability for ICD-9-CM medical procedure coding, which is consistent with our study. This high reliability rate may be attributed to review all clinical and cost-related documents, the simplicity of coding, and the repetitive nature of procedures performed on to injured patients.
Recent research on the ICHI classification system has focused on mapping it with other classification systems, nomenclature, and disease registry systems [24-27], as well as on its feasibility for implementation in audiology, nursing, public health, reporting, statistics, and reimbursements [12, 28-30]. Few studies have investigated documentation deficiencies in medical records using ICHI. This study revealed that although documentation for ICD-9-CM coding was complete in all cases, the completeness rate dropped to 51% for ICHI. Furthermore, the most common documentation deficiencies for ICHI coding were related to Means (44%) and Target (12%). Fung et al. [31] reported the highest documentation deficiencies in Means (67%) and Target (33%), which contradicts our results. Because procedure registration forms (especially the surgery report) are completed by physicians after the procedure, documentation may be incomplete due to physician fatigue in immediate documentation process or forgetfulness during delayed documentation. Therefore, it is necessary to inform physicians on the importance of complete documenting all details. Poor documentation of medical interventions in medical records significantly impacts the quality of ICHI coding. A lack of adequate detail on interventions and their outcomes [29], along with interventions involving multiple targets or actions, complicates the application of the ICHI system. Additionally, the distinction between action and means in coding poses further challenges [12].
Limitations
This study has some limitations. First, this study focused on medical interventions related to trauma, poisoning, and external causes, which may not be representative of all types of medical interventions performed in the hospital. Second, the ICHI system is not currently implemented for coding medical interventions in Iran, and the lack of ICHI coded data by hospital coders prevented direct evaluation of ICHI coding accuracy. Finally, since this study was conducted in only one hospital, the findings cannot be generalized to all hospitals in Bandar Abbas.
Conclusion
The accuracy of medical record coding using ICD-9-CM was found to be low. Despite relatively complete documentation, the error rate in ICD-9-CM coding remained high. The adequacy of medical record documentation for ICD-9-CM coding was higher compared to ICHI. Therefore, in addition to improving the documentation of procedures, it is necessary to improve the accuracy of intervention coding. The ICHI requires more detailed information than the ICD-9-CM. To improve documentation quality, it is essential to develop standardized ICHI-compatible documentation guidelines, implement templates and reminders during data recording, raise awareness among healthcare providers about the importance of quality documentation and provide feedback on documentation quality. Additionally, to improve the accuracy of procedure coding, it is recommended to utilize automated coding support tools, conduct regular coding audits, and continuous training for coders.
Declerations
Ethical considerations: This study was approved with the ethics code IR.HUMS.REC.1400.359 obtained from the Ethics Committee for Biomedical Research of Hormozgan University of Medical Sciences.
Funding: This research was carried out with the financial support of the Vice Chancellor for Research and Technology of Hormozgan University of Medical Sciences with number 4000392. The funder had no role in data collection, data analysis and article writing.
Conflicts of interests: The authors declared that they have no conflict of interest.
Authors’ contribution: FK: Study design, data analysis, writing-original draft and final approval; NAK: Study design, data collection, writing-original draft and final approval; MHHH: Study design, data analysis, writing-original draft and final approval; MKC: Study design, data collection, writing-original draft and final approval; JA (corresponding author): Study design, data analysis, writing-original draft and final approval.
Consent for publication: Not applicable.
Data availability: Data access is possible through the corresponding author.
AI deceleration: The authors used Grammarly to edit the English part of this article. All AI-edited content has been reviewed and approved by the authors.
Acknowledgements: The authors are grateful to the Research Vice-Chancellor of Hormozgan University for providing the scientific resources for the study. In addition, the authors are grateful to all the people who helped in this research.
Procedures were classified using ICD-9-CM by hospital coders and independent evaluators. The study found that only 51% of the procedure codes assigned using ICD-9-CM were accurate. Errors in coded procedures at the level of nature and site (major errors) accounted for 87%, while errors related to approach, means, and direction (minor errors) were 13%, respectively. In Iran, Ahmadi et al. [17] reported an average accuracy rate of 89.5% for coding procedures. Additionally, Farzandipour and Sheikhtaheri [15] reported overall coding accuracy of 81%, with 97% accuracy for the primary two-digit level, and 81% for two digits after the decimal point. In England, Burns et al. [1] reported an average accuracy rate for coding medical procedures as 84%. In Malaysia, Zafirah et al. [18] reported the accuracy of coding as 51% for primary procedures and 58% for secondary procedures, which significantly impacted the implementation of DRG and hospital income. In the United States, Balla et al. [19] stated that the overall accuracy of surgical residents in coding medical procedures was 82.52%. Moreover, Beck et al. [20] reported the accuracy of coding hip fracture surgical procedures as 66%. In South Africa, Britton et al. [21] mentioned a 35% accuracy rate in coding clinical procedures and reported the negative impact of coding errors on hospital revenue. The results of our study were lower than those reported in studies [1, 15, 17, 19-20], higher than [21] and similar to study [18]. Additionally, the ICD-9-CM classification was published in 1979 and has been discontinued in many countries, with limited studies in the last decade evaluating the accuracy of procedure coding using ICD-9-CM. Most studies have focused on evaluating the impact of coding quality on reimbursement systems and hospital income [18, 20-22].
The major reason for the high rate of coding errors identified in this study was the coders' exclusive reliance on admission and discharge summary sheet, unit summary sheet, and operation report sheet. However, billing forms contain more detailed and comprehensive information about the procedures performed. Another reason for coding errors was the omission of non-surgical procedures such as gastric lavage, blood transfusion, intubation, and catheterization. In other words, the study found that coders focused only on surgical procedures, whereas all procedures, both surgical and non-surgical, should be coded. Additionally, inaccurate application of coding rules, failure to consult the alphabetic index, use of outdated coding books, incomplete medical records, and the complexity of coding process were identified as contributing factors to coding errors.
Based on the findings, the inter-rater reliability between the first and second evaluators for ICD-9-CM procedure coding was 98.6%. Daneshvar et al. [23] in Canada reported a 96% reliability for ICD-9-CM medical procedure coding, which is consistent with our study. This high reliability rate may be attributed to review all clinical and cost-related documents, the simplicity of coding, and the repetitive nature of procedures performed on to injured patients.
Recent research on the ICHI classification system has focused on mapping it with other classification systems, nomenclature, and disease registry systems [24-27], as well as on its feasibility for implementation in audiology, nursing, public health, reporting, statistics, and reimbursements [12, 28-30]. Few studies have investigated documentation deficiencies in medical records using ICHI. This study revealed that although documentation for ICD-9-CM coding was complete in all cases, the completeness rate dropped to 51% for ICHI. Furthermore, the most common documentation deficiencies for ICHI coding were related to Means (44%) and Target (12%). Fung et al. [31] reported the highest documentation deficiencies in Means (67%) and Target (33%), which contradicts our results. Because procedure registration forms (especially the surgery report) are completed by physicians after the procedure, documentation may be incomplete due to physician fatigue in immediate documentation process or forgetfulness during delayed documentation. Therefore, it is necessary to inform physicians on the importance of complete documenting all details. Poor documentation of medical interventions in medical records significantly impacts the quality of ICHI coding. A lack of adequate detail on interventions and their outcomes [29], along with interventions involving multiple targets or actions, complicates the application of the ICHI system. Additionally, the distinction between action and means in coding poses further challenges [12].
Limitations
This study has some limitations. First, this study focused on medical interventions related to trauma, poisoning, and external causes, which may not be representative of all types of medical interventions performed in the hospital. Second, the ICHI system is not currently implemented for coding medical interventions in Iran, and the lack of ICHI coded data by hospital coders prevented direct evaluation of ICHI coding accuracy. Finally, since this study was conducted in only one hospital, the findings cannot be generalized to all hospitals in Bandar Abbas.
Conclusion
The accuracy of medical record coding using ICD-9-CM was found to be low. Despite relatively complete documentation, the error rate in ICD-9-CM coding remained high. The adequacy of medical record documentation for ICD-9-CM coding was higher compared to ICHI. Therefore, in addition to improving the documentation of procedures, it is necessary to improve the accuracy of intervention coding. The ICHI requires more detailed information than the ICD-9-CM. To improve documentation quality, it is essential to develop standardized ICHI-compatible documentation guidelines, implement templates and reminders during data recording, raise awareness among healthcare providers about the importance of quality documentation and provide feedback on documentation quality. Additionally, to improve the accuracy of procedure coding, it is recommended to utilize automated coding support tools, conduct regular coding audits, and continuous training for coders.
Declerations
Ethical considerations: This study was approved with the ethics code IR.HUMS.REC.1400.359 obtained from the Ethics Committee for Biomedical Research of Hormozgan University of Medical Sciences.
Funding: This research was carried out with the financial support of the Vice Chancellor for Research and Technology of Hormozgan University of Medical Sciences with number 4000392. The funder had no role in data collection, data analysis and article writing.
Conflicts of interests: The authors declared that they have no conflict of interest.
Authors’ contribution: FK: Study design, data analysis, writing-original draft and final approval; NAK: Study design, data collection, writing-original draft and final approval; MHHH: Study design, data analysis, writing-original draft and final approval; MKC: Study design, data collection, writing-original draft and final approval; JA (corresponding author): Study design, data analysis, writing-original draft and final approval.
Consent for publication: Not applicable.
Data availability: Data access is possible through the corresponding author.
AI deceleration: The authors used Grammarly to edit the English part of this article. All AI-edited content has been reviewed and approved by the authors.
Acknowledgements: The authors are grateful to the Research Vice-Chancellor of Hormozgan University for providing the scientific resources for the study. In addition, the authors are grateful to all the people who helped in this research.
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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