clinical coding

Augmented reality (AR) is one of the new technologies that is used in education, especially medical education. This study aims to determine the requirements for developing an educational application based on AR for teaching clinical coding.

In this descriptive-comparative study conducted in 2022, we first investigated the user interface (UI) and functionality of the AR-based educational applications. The UI features were extracted from 12 similar applications in Persian and English available in Google Play and Cafe Bazaar. To determine the functionality features, the opinions of a panel of experts including professors of clinical coding from Isfahan University of Medical Sciences in Iran were used. 

The UI features included search (found in 3 applications), scanners (found in 11 applications), educational content classification (found in 9 applications), audio/text guides (found in 9 applications), and about us (found in 8 applications) sections. The functionality features included testing of knowledge and using images (2D, 3D).

Due to the theoretical and practical nature of the clinical coding course, a section to solve clinical coding scenarios is an important feature of AR-based educational applications for clinical coding. Also, the use of images (2D, 3D) in these applications can create a deeper impact on students’ learning.

In the health system, reimbursement methods are an important criterion for the allocation of resources and the performance of service providers. The use of diagnosis-related groups (DRG) system reduces the length of stay and additional costs of the patient, prevents unnecessary treatment, increases resource efficiency and transparency of health care services. The development of the DRG system focuses on the accurate documentation of medical records and the correct coding of diagnoses and procedures. The purpose of this research is to evaluate the documentation and coding requirements of medical records in the implementation of a payment system based on diagnosis-related groups in Iran.

This research was descriptive-cross-sectional and was conducted in 2022. The data collection tool was a researcher-made checklist, the validity of which was confirmed based on the opinion of experts (health information management health economics) and its reliability was obtained by calculating Cronbach’s alpha (0.83). The research population consisted of 418 medical records in five medical training centers affiliated to Urmia University of Medical Sciences, which were selected through stratified-proportional sampling. Data were analyzed using SPSS software.

The results of the evaluation of the documentation and coding requirements of medical records for the implementation of the DRG system showed that the demographic/administrative variables including age, sex, type of admission, length of stay, health insurance, and doctor’s expertise were completely recorded. Evaluation of clinical variables also showed that the main diagnosis, main procedure, secondary diagnosis and other procedures were documented in medical records in 98%, 97%, 88% and 75% respectively. Regarding the coding of the main diagnosis and the main procedure, 100%, secondary diagnosis 68% and other procedures 80% have been done.

Considering that some essential clinical variables for the implementation of DRG, especially co-morbidities, complications and other procedures are not recorded separately and completely, therefore it is necessary to define separate information elements in medical records and HIS for accurate recording of these variables and proper interaction between coders and doctors is established to increase the possibility of correct coding. It is also suggested that the DRG system be implemented in our country in a phased and gradual approach so that necessary changes are made in the documentation process and hospital information systems.

Clinical coding is a complex and error-prone process. Correct clinical coding requires high-quality documentation of medical records. This study aimed to identify the quality of medical records documentation and the accuracy of coding with ICD-10 compared to ICD-11.

This cross-sectional descriptive study was conducted in 2022. The samples were chosen from 11638 medical records of patients admitted at the Shahid Mohammadi teaching hospital with the diagnosis of injury, poisoning, and certain other consequences of external causes. Using Cochran's formula, 500 medical records were evaluated. The research was conducted in two stages to check the accuracy of coding and the defects in the documentation of medical records for coding. The research data collection tools were separate checklists for each stage. Data were analyzed using descriptive statistics in SPSS software.

The number of codes allocated to the studied medical records was 1673 and 1468 codes based on ICD-10 and ICD-11 classification systems, respectively. The majority of records (98%) had at least one type of major or minor error, 23% had only major errors, 46% had only minor errors, and 31% had both types of ICD-10 coding errors. Moreover, 81% and 26% of the medical records contained adequate information to fully or relatively fully describe the codes using ICD-10 and ICD-11 classification systems, respectively.

Compared to ICD-10, there were more defects in the documentation of medical records for coding with ICD-11. Development written documentation guidelines by ICD-11, using templates and reminders, and providing feedback to healthcare providers. Using automated coding support tools, coding audits, and continuous training of coders are essential for coding quality improvement.

In Iran, the tariffs’ book of “Relative Values of Health Services” is the basis for calculating the costs of health services. Since orthopedic surgery is one of the largest fields of surgery in which most body tissues are involved, coding orthopedic procedures is more difficult. The present study aims to investigate the problems of coding orthopedic procedures using the Tariffs’ book.

This descriptive cross-sectional study was conducted in 2020 in university and non-university hospitals of Ahvaz, Iran. Participants were 73 people including orthopedic physicians, insurance experts, and revenue auditors who were selected by a census method. A questionnaire in two paper and online forms was used to collect information. The collected data were analyzed in SPSS software, version 22.

Among the problems of coding common in three groups, the biggest problem was related to the lack of an intelligent system for calculating the percentage of codes if they were multi-codes (78.75%). Regarding the adjustment codes, the highest level of familiarity was related to the code 51 about multiple surgeries (64.82%), and the lowest level was related to the code 20 about independent surgery ( 55.76 % ).

The development of an intelligent software for coding orthopedic procedures in Iran can facilitate the coding process and reduce the coding errors.

 Medical records can be defined as a document of the patients' treatment process. Complete and accurate information recording in the medical records of poisoned patients can play an important role in their complete clinical coding. This study aims to determine the amount of registered information required for clinical coding in the medical records of poisoned patients admitted to Imam Reza Hospital in Mashhad, Iran.

 This descriptive cross-sectional study was conducted in 2019. 387 records were selected and reviewed by simple random sampling from all medical records of patients admitted to the poisoning ward of Imam Reza Hospital of Mashhad University of Medical Sciences. The instrument was a valid and reliable checklist. Data analysis was conducted using descriptive statistics.

 The type of poisoning was registered in 387 (100%) medical records and in only 20 (5.2%) medical records the poisoning substance was an unknown drug. In 183 (47.3%) medical records, an external cause was registered for the poisoning, with 19 (4.9%) and 1 (0.3%) medical records including the individual's place of exposure and activity during exposure, respectively.

 The findings of this study can be used to plan and compile the necessary guidelines for the proper accurate documentation of medical records and the possibility of high quality clinical coding.