Coding errors of cataract surgeries: analysis and discussions / 中华医院管理杂志

Objective To study the problems encountered in the coding of cataract surgeries. Methods Medical record statistical system was used to retrieve 213 such patients discharged from a hospital between January and June 2016. ICD-9-CM-3 coding principle was called into play to analyze the form completion and coding of major surgeries, along with errors found in them. Results Study of the 213 medical records identified 12 errors of surgery form completion from the surgeons′medical record homepages, accounting for 5. 6% of all. With reference to ICD-9-CM-3, 188 errors were found from the surgical coding made by encoders, accounting for 88. 3% of all. 10 copies were missing with surgery coding, accounting for 4. 7%. 13 coding errors were found in major surgical choices, accounting for 6. 1%. Conclusions Failure of the encoders in their command of coding rules for cataract surgery tops the rest as the main reason for the error of surgical coding. Encoders should make effective use of the ICD-9-CM-3 manual, and master both clinical knowledge, professional skill and coding ability.

Organization of Maximum Surgical Blood Order Schedule (MSBOS) according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) / 대한수혈학회지

BACKGROUND: The aim of this study is to organize the maximum surgical blood order schedule (MSBOS) of red blood cells (RBCs) for elective surgeries according to the International Classification of Diseases, Ninth Revision, Clinical Modification guidelines (ICD-9-CM) and we compared the results with the previously reported MSBOSs. METHODS: From 1 March to 31 August 2007, the data of the transfused RBCs for elective surgeries in our hospital were analyzed. The MSBOS was organized as the average number of units of transfused RBCs for the type of surgery, according to the ICD-9-CM. The results were compared with the MSBOSs that were previously reportedfrom 1982 to 2004 in Korea. RESULTS: A total of 121 types of 3,375 surgeries were performed. Type & screen for 91 types (81.3%), 1 unit for 20 types (13.8%), 2 units for 7 types (3.8%), 3 units for 1 type (0.4%) and 4 units for 2 types (1.8%) were recommended. There was a minimal difference between these results and the range for the previously reported MSBOSs. CONCLUSION: It seems that the MSBOS showed minimal change since 2004. We organized the MSBOS according to the guidelines of the ICD-9-CM. Standardization of the surgery name should be considered to achieve more useful utilization of MSBOS.

A Study on coding application of ICD-9 / 대한의료정보학회지

In Korea medical record administrators/technicians are coding diagnoses and procedures of discharged patients based on their medical records mostly using International Classification of Diseases, 9th revision(ICD-9) and International Classification of Procedures(ICPM) by WHO. This study examined consistency of coding in 63 hospitals in the year of 1992. The statistical data showed great inconsistency in coding patterns among many hospitals. The main reasons of inconsistency were coders errors, ill-defined diagnoses/procedures, no unified route to make new code numbers for the new or ambiguous diagnoses/procedures, inconsistency of selection of using optional(additional) codes, and inconsistency of reference records on coding. Near half of the hospitals do not recheck the accuracy of coding after completion of medical records by physicians. Most of the coders review operation record, admission and discharge record, discharge summary, progress notes, pathology report, and consultation record as references on coding, but 14 hospitals do not review the whole record when they code diagnoses and procedures. Twenty-three hospitals discuss with physicians when they have questions in assigning code numbers. Further study should be done continuously for valid and reliable statistics of diseases and operations and for establishing a systematic unified channel for the new and ambiguous cases.