Quality of documentation of medical records and coding accuracy of ICD-10 versus ICD-11

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.