PubMed Health⌕ Search

SEARCH · PubMed Health

Results for “Clinical Coding”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 55 records · Page 3Linked to original sources
PubMedDate not supplied

Matching ICD-9-CM codes to clinical indicators--is it the way to go?

In early 1997, the Australian Council on Healthcare Standards (ACHS) Care Evaluation Program (CEP) collaborated with the National Centre for Classification in Health (NCCH) to determine the feasibility of matching ICD-9-CM codes with a selected number of clinical indicators developed by CEP. While the results of this activity were encouraging, CEP is hesitant in advocating the use of ICD-9-CM as the complete answer to the data collection 'burden' experienced by health care organisations collecting clinical indicator data. CEP is concerned that obtaining clinical indicator data through ICD-9-CM coding alone may limit clinician participation in quality activities, narrow the focus of performance monitoring to one department, potentially compromise the intent of the indicators, and encourage a culture of 'near enough is good enough'. This paper examines the limitations of ICD-9-CM coding as the sole means of extracting clinical indicator data.

Abstracting and Indexing↗
PubMed2006

Validity of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for Acute Renal Failure.

Administrative and claims databases may be useful for the study of acute renal failure (ARF) and ARF that requires dialysis (ARF-D), but the validity of the corresponding diagnosis and procedure codes is unknown. The performance characteristics of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for ARF were assessed against serum creatinine-based definitions of ARF in 97,705 adult discharges from three Boston hospitals in 2004. For ARF-D, ICD-9-CM codes were compared with review of medical records in 150 patients with ARF-D and 150 control patients. As compared with a diagnostic standard of a 100% change in serum creatinine, ICD-9-CM codes for ARF had a sensitivity of 35.4%, specificity of 97.7%, positive predictive value of 47.9%, and negative predictive value of 96.1%. As compared with review of medical records, ICD-9-CM codes for ARF-D had positive predictive value of 94.0% and negative predictive value of 90.0%. It is concluded that administrative databases may be a powerful tool for the study of ARF, although the low sensitivity of ARF codes is an important caveat. The excellent performance characteristics of ICD-9-CM codes for ARF-D suggest that administrative data sets may be particularly well suited for research endeavors that involve patients with ARF-D.

Acute Kidney Injury↗
PubMedDate not supplied

Coding for clinical trials.

Although CMS reimburses for routine care associated with clinical trials, it is essential that the correct diagnosis code, modifier, and, where necessary, HCPCS Level II procedure code be assigned to accurately report these qualifying trial services. Remember that not all insurance payors will provide reimbursement for services rendered as part of a clinical trial, and individual payor policies should be obtained and followed for these services.

Clinical Trials as Topic↗
PubMed1993

Data collection and changing health care systems. 1. United Kingdom.

The adoption of "Read Clinical Codes" for computerised patient records could profoundly alter the nature and quality of Western medicine in the next decade. The increasing awareness of the need for a standardised coding system has led to the funding of a pilot project to test Read codes in Australian general practice. Read codes are a comprehensive nomenclature of clinical terms incorporating over 100,000 codes in a structured hierarchical form. Designed by a general practitioner, they are now owned, controlled, and developed by the British National Health Service (NHS). Selected as the basis for clinical coding across the NHS, they form the cornerstone of computerised patient records. Computer use has been encouraged in general practice in the UK, with financing schemes and functional inducements resulting in 70% of practices being at least partly computerised, and 84% of these using Read codes. Their promotion has been backed by a major development program to broaden the codes to include all clinical specialities, nursing, and professions allied to medicine. The codes will require significant adaptation for Australian use, including the development of an administrative chapter and a pharmaceutical classification. The impact of information management systems on health care in the UK has relevance for the continuing development of the Australian National Health Information Strategy and for future record keeping in general practice in Australia. If the trial proves successful, the adoption of Read codes as a standard for information management in patient medical records will need to be considered.

Abstracting and Indexing↗
PubMed2002

4.2 Clinical records and global diagnostic codes.

A clinical record should include the personal demographic details of the patient, health status, diagnostic information and management/treatment options. However, clinical records are of little use without effective filing and retrieving systems. Coding is therefore necessary to deal with large amounts of differing data and a global coding system could be effectively developed through the use of information technology. The aim of this section was to review the main existing vocabularies and coding systems and to examine ways of improving their global application. It was concluded that global diagnostic codes would be beneficial to the patient, to the profession and to those responsible for strategic decisions concerning the delivery of health care. Extant dental clinical codes are not accepted widely or applied universally. There is an urgent need to identify existing coding systems and to assess their utility and potential for global application. Every effort should be made to include existing codes in the development of a global coding system on which all specialist areas would need to agree. This would require the provision of an overarching interdisciplinary focus and funding should be made available for this development and its implementation.

Cultural Diversity↗
PubMed1997

International Classification of Diseases, 9th Revision, Clinical Modification codes in discharge abstracts are poor measures of complication occurrence in medical inpatients.

OBJECTIVES: The authors tested the ability of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in discharge abstracts to identify medical inpatients who experienced an in-hospital complication, using complications identified through chart review as the gold standard. METHODS: Two sets of ICD-9-CM codes were used: an inclusive set including many medical diagnoses that may also be coexistent complicating conditions on admission rather than complications and an exclusive set consisting primarily of ICD-9-CM-specified complication and adverse drug event codes. RESULTS: Neither set performed well as a diagnostic test for complication occurrence according to receiver operating characteristic analysis (ROC areas were 0.61 for the inclusive set and 0.55 for the exclusive set). Sensitivities of the ICD-9-CM codes for complications were 0.34 for the inclusive set and 0.14 for the exclusive set. Corresponding positive predictive values were 0.32 and 0.37, respectively. Sensitivities of code definitions for individual complications were generally poor, less than 0.5 in most cases. CONCLUSIONS: The authors conclude that ICD-9-CM codes in discharge abstracts are poor measures of complication occurrence.

Abstracting and Indexing↗
PubMed2006

Performance of International Classification Of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.

BACKGROUND: Adverse drug events (ADEs) are one of the most frequent causes of iatrogenic injury. Because International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes are routinely assigned to inpatient discharges, they could provide a method to detect ADEs within a hospital, a state, and the nation. OBJECTIVE: The objective of this study was to determine validity of selected ICD-9-CM codes in identifying inpatient ADEs. RESEARCH DESIGN: An expert panel identified 416 ICD-9-CM codes to represent ADEs (flagged ADE codes). Retrospective chart review using a structured tool was performed to ascertain code performance in detecting ADEs. SUBJECTS: Subjects included 3103 inpatients from all 41 acute care hospitals in Utah in 2001: 1961 inpatients sampled randomly (random sample) and 1142 inpatients sampled from the discharge records with at least one flagged ADE code (flagged sample). MEASURES: Measures were ADEs identified by structured review. RESULTS: The flagged sample yielded 1122 flagged ADE codes recorded in patient charts with 704 representing ADEs (63%). Two hundred eighty-six of the 704 verified ADE codes (41%) were determined to be inpatient ADEs. In the random sample, 32 of 58 ADEs (55%) causing hospital admission were detected by the ADE-flagged codes. Only 23 of 224 inpatient ADEs had been assigned a flagged ADE code (10%). CONCLUSIONS: Flagged ADE codes have an overall positive predictive value of 63% and detect just over half of ADEs causing hospital admission. These codes have a positive predictive value of 25% for inpatient ADEs but detect only 10% of overall inpatient ADEs. Flagged ADE codes provide an imperfect but immediately available ADE surveillance system.

Adverse Drug Reaction Reporting Systems↗
PubMed2001

Echo-enhanced transcranial color-coded US: clinical usefulness of intravenous infusion versus bolus injection of SH U 508A.

Twelve patients with insufficient transcranial Doppler signal underwent transcranial color-coded ultrasonography before and after administration of SH U 508A with different modes of administration. Clinically useful enhancement time after bolus injection was surpassed by that after standard infusion (1 mL/min), whereas further prolongation was observed after individualized infusion. Intravenous infusion of SH U 508A provides a prolonged useful enhancement compared with that after bolus injection.

Contrast Media↗
PubMed2000

An overview of coding and its relationship to standardized clinical terminology.

Coding systems and standardized clinical terminologies are interrelated. Coding schemes can be developed for classification systems, nomenclatures, and clinical terminologies. The coding systems most commonly used in the United States lose clinical detail and cannot meet the demands of the clinical information systems needed to support the computer-based patient record, outcomes studies, or risk-adjusted comparative research. Systems using computerized encoding and structured as terminologies offer more promise of providing the needed clinical detail. Companion systems can be developed to automatically place standardized clinical terms into less granular classification systems, such as ICD-9-CM, to maintain international compatibility and to continue federal programs based on such classifications.

Abstracting and Indexing↗
PubMed1999

Semantic based concept differential retrieval & equivalence detection in clinical terms version 3 (Read Codes).

Modern clinical terminologies are required to provide a large corpus of concepts to cover the complexity of medicine. It is well recognised that sufficient scalability is likely to be achieved only with those schemes that can build post-coordinated constructs compositionally. Clinical Terms Version 3 (Read Codes) uses a system of templates to both express the semantic definition (atoms) of concepts and to allow qualification of core concepts with additional detail. This common mechanism for expressing both intrinsic semantic information and additional information allows both pre- and post-coordinated concepts to be retrieved from different perspectives and to detect equivalence between alternative representations of the same concept. The practical application and experience of such an approach is described in relation to a live clinical database (Diabeta). The merits of such an approach are outlined and its relationship to other documented mechanisms outlined.

Classification↗
PubMed1997

Use of dietetic-specific nutritional diagnostic codes in clinical reasoning relevant to the nutritional management of core clinical outcome indicators in hemodialysis patients.

The Health Care Financing Agency (HCFA) has recommended conscientious monitoring of four core outcome indicators (anemia, albumin, treatment adequacy, and hypertension) by the end stage renal disease (ESRD) health care team. Dietetic-specific nutritional diagnostic categories (D-S NDCs) can be a powerful tool in guiding renal nutrition specialists through the clinical reasoning required to diagnose and clinically correct nutrition-related problems in hemodialysis (HD) patients. The purpose of this article is to portray one clinician's dual use of D-S NDCs to identify the nutritional problem responsible for poor performance and determine nutritionally treatable causes. Although four indicator-specific sets of D-S NDCs commonly used in the nutritional assessment of anemia, albumin, treatment adequacy and hypertension were identified and referenced, seven codes were consistently repeated. These D-S NDCs were (1) altered nutritional biochemistry integrity; (2) absence of/limited nutritional service; (3) deficit in nutrition knowledge; (4) imbalance of nutrient/fluid; (5) nutrition misinformation; (6) toxicity of nutrient/nutrient end-product; and (7) possibility of developing a specific disease. Thus, in ESRD, use of D-S NDCs shows the implicit role of the registered dietitian in disease prevention, management of altered nutrient disposition, and patient education.

Dietetics↗
PubMed2005

Strategies for referent tracking in electronic health records.

The goal of referent tracking is to create an ever-growing pool of data relating to the entities existing in concrete spatiotemporal reality. In the context of Electronic Healthcare Records (EHRs) the relevant concrete entities are not only particular patients but also their parts, diseases, therapies, lesions, and so forth, insofar as these are salient to diagnosis and treatment. Within a referent tracking system, all such entities are referred to directly and explicitly, something which cannot be achieved when familiar concept-based systems are used in what is called "clinical coding." In this paper, we describe the components of a referent tracking system in an informal way and we outline the procedures that would have to be followed by healthcare personnel in using such a system. We argue that the referent tracking paradigm can be introduced with only minor--though nevertheless ontologically important--technical changes to existing EHR infrastructures, but that it will require a radically different mindset on the part of those involved in clinical coding and terminology development from that which has prevailed hitherto.

Computational Biology↗
PubMed1975

A clinically useful coding system for normal coronary artery anatomy.

Cine coronary arteriograms of 121 patients with normal coronary arteriograms with and without associated valvular or myocardial disease were reviewed to describe normal coronary artery anatomy and the distribution of potentially graftable vessels. Coronary arterio grams were divided into right, mixed, and left interior emphasis systems, depending upon the blood supply to the inferior surface of the left ventricle. Whether a coronary artery at its origin was less than 50%, between 50-70% of the left anterior descending coronary artery (LAD) at its origin was described in a simple lettering and numbering code to allow easy comparison. The diameter of the LAD at its origin averaged 4.2 mm. All vessels greater than 70% of the LAD were clearly graftable. The frequency (in percent) with which that vessel was greater than 70% of the LAD in right, mixed, and left systems, respectively, was as follows: right coronary artery 100. 100. 0. LAD 100. 100. 100. intermediate artery 8.7 12.5 33.3 obtuse marginal artery 53.7 43.7 44.4 atrioventricular groove artery 0. 56.2 100. diagonal branch of the LAD 15. 6.3 11.1. This simple method of classification is recommended to provide more accurate comparison in published series and to assist the coronary arteriographer in his interpretations.

Adult↗
PubMed2006

Clinical documentation, coding, and billing.

Practitioners must be aware of ever-changing requirements for documentation and correct diagnostic and procedural coding for billing. These requirements are often dependent on the setting, and clinicians who practice in more than one setting have to understand multiple regulations and guidelines. Some practices are dictated by the payer, such as precertification or using a specific form (e.g., HCFA 1500) to submit the charges. Documentation of services provided encompasses evaluation reports, treatment plans, recertifications, and discharge summaries. Different forms and formats are required in different settings and by different payers. The clinician must document in a clear and concise format that can be understood by others. When documentation is completed accurately and well, reimbursement for services is more likely.

Forms and Records Control↗
PubMed1998

A practice-based survey of familial age-related maculopathy.

PURPOSE: We evaluated the efficacy of a practice-based survey of age-related maculopathy (ARM) to identify potential families for molecular genetic studies. Demographic and ophthalmic features of the eligible study population were compared with responders and with individuals who reported a positive family history of ARM. METHODS: Individuals seen within a three-year period in a comprehensive ophthalmic practice were identified through billing codes. Clinical records were reviewed, coded, and merged with questionnaire responses. Patient identifiers were removed prior to analyses. RESULTS: There were no significant differences between the respondents and the eligible cohort with respect to gender, age, or type of macular degeneration. Comparable percentages of younger and older individuals with ARM reported positive family histories. The distribution of atrophic macular degeneration, choroidal neovascular membranes, and milder forms of the disease among the individuals reporting positive family histories corresponded to the distribution of the entire eligible cohort of patients. CONCLUSIONS: This recruitment strategy for ARM families is cost-effective and confirmed a high prevalence of familial ARM. The respondents are representative of the general ARM population. This approach is applicable for other ophthalmic genetic conditions.

Aged↗