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PubMed2003

Textual content, health problems and diagnostic codes in electronic patient records in general practice.

OBJECTIVE: To investigate textual content, health problems and diagnostic codes in everyday electronic patient records. DESIGN: Retrospective and observational database study. SETTING: Primary health care in Stockholm. SUBJECTS: Twenty randomly selected general practitioners with 20 records each. MAIN OUTCOME MEASURES: The frequency of use of problem-oriented medical records. The number of words, problems and diagnostic codes. The completeness and correctness of the diagnostic codes. RESULTS: About 14.5% of 400 studied records were problem-oriented. The mean number of words per record was 99.4, and the mean number of problems managed per record was 1.2. On average, there were 1.1 diagnostic codes per record and this differed widely among GPs and also among the electronic patient record systems. The mean number of codes per problem was 0.9, and the proportion of correct codes was 97.4%. CONCLUSIONS: The electronic patient records in general practice in Stockholm have an extensive textual content. A vast majority of the problems are coded and the completeness and correctness of diagnostic codes are high. It seems that problem-oriented electronic patient record systems enforce coding activities. It is feasible to establish a database of diagnostic data for research and health care planning based on electronic patient records.

Disease↗

PubMed1986

Age-related effects of spatial contiguity and interference on coding performance.

This study investigated the effects of spatial contiguity of coding key and coding row and interference from irrelevant stimuli on the coding performance of young and older adults. The young coded faster than older adults, and they were unaffected by the presence of irrelevant stimuli. The old group was significantly slower when irrelevant rows of coding material were present, regardless of the spatial placement of such stimuli. Interference may partially explain the difficulty older adults experience on coding tasks, but it has a similar effect on sequential psychomotor task performance other than coding. Spatial contiguity of coding key and coding row did not influence the performance of either age group. Both groups improved with practice over trials, but the old group improved to a greater degree, particularly on the initial trials.

Adolescent↗

PubMed1992

Death certificate coding practices related to diabetes in European countries--the 'EURODIAB Subarea C' Study.

The objective of this study was to compare and analyse coding practices for diabetes mortality data in nine European countries (Belgium, Republic of Ireland, France, Germany, Malta, The Netherlands, Northern Ireland, Scotland and Switzerland). In each country, a sample of 200 coded death certificates, which mentioned diabetes, was randomly sampled. All death certificates were recoded at the WHO Collaborating Centre for the Classification of Diseases in the French language. The results show wide differences between national coding and central coding. Discrepancies in the underlying cause of death existed at the 3-digit coding level for 26% of all death certificates and for 44% at the 4-digit level. Coding in Northern Ireland and Malta was characterized by a marked tendency to choose diabetes less frequently. In contrast, in The Netherlands and, to a lesser extent, in the Republic of Ireland and France, diabetes was more frequently selected as the underlying cause of death. Most of the differences concerned the coding of an association involving diabetes and circulatory system diseases. In some countries, these coding differences influence the reported level of diabetes mortality. For Northern Ireland and Malta, the number of certificates with diabetes as the underlying cause of death was more than doubled after central recoding and for The Netherlands, in contrast, it was almost halved. To explain the differences a number of factors are considered: a lack of information from the International Classification of Diseases (ICD), on the application of the coding rules, between-country differences in cause of death certification practices, a divergence of opinion about the causal role of diabetes when it is associated with other conditions, a lack of homogeneity between countries in data collection procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Cause of Death↗

PubMed2002

Congruent evolution of different classes of non-coding DNA in prokaryotic genomes.

Prokaryotic genomes are considered to be 'wall-to-wall' genomes, which consist largely of genes for proteins and structural RNAs, with only a small fraction of the genomic DNA allotted to intergenic regions, which are thought to typically contain regulatory signals. The majority of bacterial and archaeal genomes contain 6-14% non-coding DNA. Significant positive correlations were detected between the fraction of non-coding DNA and inter- and intra-operonic distances, suggesting that different classes of non-coding DNA evolve congruently. In contrast, no correlation was found between any of these characteristics of non-coding sequences and the number of genes or genome size. Thus, the non-coding regions and the gene sets in prokaryotes seem to evolve in different regimes. The evolution of non-coding regions appears to be determined primarily by the selective pressure to minimize the amount of non-functional DNA, while maintaining essential regulatory signals, because of which the content of non-coding DNA in different genomes is relatively uniform and intra- and inter-operonic non-coding regions evolve congruently. In contrast, the gene set is optimized for the particular environmental niche of the given microbe, which results in the lack of correlation between the gene number and the characteristics of non-coding regions.

DNA, Intergenic↗

PubMed2002

Coding of diagnoses, comorbidities, and complications of total hip arthroplasty.

International Classification of Diseases coding of patient charts is used by hospitals to allow for billing of patients. Coding information also is used for assessing physician effectiveness. The purpose of the current study was to examine hospital coding for patients having total hip arthroplasty. One hundred consecutive primary total hip replacements were done at one medical center by two orthopaedic surgeons. Patient charts were coded by hospital coders according to the Health Care Finance Administration guidelines. Subsequently, an orthopaedist-based team did a secondary review of these charts and the two sets of codes were compared. The diagnostic codes were similar between the two groups for 87% (174 of 200 codes) of the cases. Comorbidities generally were undercoded by the hospital coders who reported 2.9 comorbidities per patient, whereas the secondary review reported 3.7 comorbidities per patient. The hospital coders found a complication rate of 1.2 per patient, whereas the secondary review revealed a rate of 0.4 per patient. Based on the results of the current study, the authors conclude that it is important to ensure three issues regarding the standard of coding and quality control: (1) the qualifications of the coders; (2) an interaction between coders and healthcare professionals to check that coding is accurate and reproducible; and (3) communication among various health professionals (including the primary surgeon) and coders to determine what actually are appropriate diagnoses, comorbidities, and complications.

Arthroplasty, Replacement, Hip↗

PubMed2000

Does clinical evidence support ICD-9-CM diagnosis coding of complications?

BACKGROUND: Hospital discharge diagnoses, coded by use of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), increasingly determine reimbursement and support quality monitoring. Prior studies of coding validity have investigated whether coding guidelines were met, not whether the clinical condition was actually present. OBJECTIVE: To determine whether clinical evidence in medical records confirms selected ICD-9-CM discharge diagnoses coded by hospitals. RESEARCH DESIGN AND SUBJECTS: Retrospective record review of 485 randomly sampled 1994 hospitalizations of elderly Medicare beneficiaries in Califomia and Connecticut. MAIN OUTCOME MEASURE: Proportion of patients with specified ICD-9-CM codes representing potential complications who had clinical evidence confirming the coded condition. RESULTS: Clinical evidence supported most postoperative acute myocardial infarction diagnoses, but fewer than 60% of other diagnoses had confirmatory clinical evidence by explicit clinical criteria; 30% of medical and 19% of surgical patients lacked objective confirmatory evidence in the medical record. Across 11 surgical and 2 medical complications, objective clinical criteria or physicians' notes supported the coded diagnosis in >90% of patients for 2 complications, 80% to 90% of patients for 4 complications, 70% to <80% of patients for 5 complications, and <70% for 2 complications. For some complications (postoperative pneumonia, aspiration pneumonia, and hemorrhage or hematoma), a large fraction of patients had only a physician's note reporting the complication. CONCLUSIONS: Our findings raise questions about whether the clinical conditions represented by ICD-9-CM codes used by the Complications Screening Program were in fact always present. These findings highlight concerns about the clinical validity of using ICD-9-CM codes for quality monitoring.

Aged↗

PubMed2006

Evaluation and management codes: from current procedural terminology through relative update commission to Center for Medicare and Medicaid Services.

BACKGROUND: Physicians should have a working knowledge of the process by which patient care codes are created and subsequently assigned values. The Society of Critical Care Medicine has representatives on the national committees that focus on code creation and definition and on assignment of relative value units. In addition, a better understanding of documentation requirements and the audit process will facilitate improved compliance and minimize liability. DISCUSSION: The authors discuss the current procedural terminology (CPT) process for defining care codes and the relative update commission (RUC) process for assigning values to those codes, with each code assigned a separate value in three separate categories. Steps for managing any concern or dispute about billing, denials, or an audit are subsequently addressed. Tenets of proper documentation are discussed, and some future developments are identified that are likely to affect critical care. CONCLUSION: Knowledge of the procedures by which care codes are defined and valued is necessary for using these codes properly, as well as for addressing needs unmet by existing codes. Preventing audits is the best approach to proper coding and billing, and documentation is key.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2005

Survey of academic pediatric emergency departments regarding use of evaluation and management codes.

OBJECTIVE: The aims of the study were to determine the frequency at which each emergency medicine evaluation and management (E/M) code is used, to identify factors associated with their use by academic pediatric emergency departments (PEDs), and to compare PED E/M code utilization rates with rates reported by Centers for Medicare and Medicaid Services for general emergency departments (EDs). METHOD: A 24-question survey was sent to 42 academic PED medical directors. Questions pertained to PED demographics, physician staff, records/documentation, billing education, and E/M coding data for 1 year. The general ED E/M code utilization rates were obtained from the published Centers for Medicare and Medicaid Services database. Descriptive statistics and odds ratios were used to report and compare the data. RESULTS: Twenty (48%) of the surveys were returned, and 9 (21%) completed the E/M coding data questions. From these 9 departments, the mean PED annual census was 46,065 (range, 23,531-92,910). The methods of PED medical record documentation were template (6), handwritten (2), and dictation/transcription (1). Charge documents were completed by the PED physician (3), professional service coders (4), and hospital coders (2). Coding/documentation in-services were provided to the physicians of 7 PEDs, and billing audits were performed in 5 PEDs. The total number of charges for the 9 PEDs was 325,129, 78.4% of the census. Multiple reasons were given for the discrepancy between census and charges. The percentage of each of the 5 levels of service billed was calculated for each of the 9 PEDs. The 2 lowest levels of service were used 38.3% of the time, whereas the 2 highest were used 19.2% of the time. The range for the highest level of service varied widely from 5.3% to 53.3%. Approximately 65% of E/M codes used by general EDs were for the 2 highest levels of service. The PED with the highest percentage of upper level charges (53.4%) was the only PED that used dictation/transcription for documentation. CONCLUSION: Although the response rate was low, and thus the validity of the results was limited, the findings may serve as a benchmark for E/M code utilization in PEDs. The large variation in use of the E/M codes among the PED in our study and the lower rate of using the highest E/M codes by the PEDs compared with the general EDs suggest potential opportunities for academic PEDs to improve billing practices.

Academic Medical Centers↗

PubMed1983

Respiratory syncytial virus mRNA coding assignments.

The polypeptide coding assignments for six of the respiratory syncytial virus-specific mRNAs were determined by translation of the individual mRNAs in vitro. The coding assignments of the RNAs are as follows. RNA band 1 is complex and can be separated into at least two components on the basis of electrophoretic mobility (molecular weights [MWs] approximately equal to 0.21 X 10(6) and 0.31 X 10(6), respectively) that code for three polypeptides of 9.5, 11, and 14 kilodaltons (K). RNA 2 (MW, 0.39 X 10(6)) codes for a 34K polypeptide; RNA 3 (MW, 0.40 X 10(6)) codes for a 26K polypeptide; RNA 4 (MW, 0.47 X 10(6)) codes for a 42K polypeptide; and RNA 5 (MW, 0.74 X 10(6)) codes for a 59K polypeptide. By limited-digest peptide mapping, the 34, 26, and 42K polypeptides synthesized in vitro appeared to be unique. Additionally, peptide mapping showed that the 34, 26, and 42K polypeptides synthesized in vitro were indistinguishable from their counterparts synthesized in infected cells. Thus, the 34, 26, and 42K polypeptides coded for by mRNAs 2, 3, and 4, respectively, were identified as the respiratory syncytial virus phosphoprotein (34K), matrix protein (26K), and nucleocapsid protein (42K), respectively. RNA 5 was shown to code for a 59K polypeptide. The 59K polypeptide synthesized in vitro did not comigrate with any polypeptide specific to infected cells, suggesting that it is a candidate for co- or post-translational modification.

Capsid↗

PubMed1999

Mechanistic basis for coding end sequence effects in the initiation of V(D)J recombination.

V(D)J recombination is directed by recombination signal sequences. However, the flanking coding end sequence can markedly affect the frequency of the initiation of V(D)J recombination in vivo. Here we demonstrate that the coding end sequence effect can be qualitatively and quantitatively recapitulated in vitro with purified RAG proteins. We find that coding end sequence specifically affects the nicking step, which is the first biochemical step in RAG-mediated cleavage. The subsequent hairpin formation step is not affected by the coding end sequence. Furthermore, the coding end sequence effect can be ablated by prenicking the substrate, indicating that the coding end effect is specific to the nicking step. In reactions in which both 12- and 23-substrates are present, a suboptimal coding end sequence on one signal can slow down hairpin formation at the partner signal, a result consistent with models in which coordination between the signals occurs at the hairpin formation step. The coding end sequence effect on nicking and the coupling of the 12- and 23-substrates explains how hairpin formation can be rate limiting for some 12/23 pairs, whereas nicking can be rate limiting when low-efficiency coding end sequences are involved.

Allergens↗

PubMedDate not supplied

Automated mapping of observation codes using extensional definitions.

OBJECTIVE: To create "extensional definitions" of laboratory codes from derived characteristics of coded values in a clinical database and then use these definitions in the automated mapping of codes between disparate facilities. DESIGN: Repository data for two laboratory facilities in the Intermountain Health Care system were analyzed to create extensional definitions for the local codes of each facility. These definitions were then matched using automated matching software to create mappings between the shared local codes. The results were compared with the mappings of the vocabulary developers. MEASUREMENTS: The number of correct matches and the size of the match group were recorded. A match was considered correct if the corresponding codes from each facility were included in the group. The group size was defined as the total number of codes in the match group (e.g., a one-to-one mapping is a group size of two). RESULTS: Of the matches generated by the automated matching software, 81 percent were correct. The average group size was 2.4. There were a total of 328 possible matches in the data set, and 75 percent of these were correctly identified. CONCLUSIONS: Extensional definitions for local codes created from repository data can be utilized to automatically map codes from disparate systems. This approach, if generalized to other systems, can reduce the effort required to map one system to another while increasing mapping consistency.

Algorithms↗

PubMed2003

Evaluation of the quality of coding of job episodes collected by self questionnaires among French retired men for use in a job-exposure matrix.

BACKGROUND: and AIMS: The ESPACES study was intended to identify retirees who may have been, according to their job descriptions, exposed to asbestos during their working lives. As part of this study, we analysed the quality of the occupation and activity sector coding as well as its effect on the subjects' exposure status. METHODS: The occupation and activity sector for a sample of 450 retired men were coded twice (with the second coder blinded to the first result), according to the international codes for industries (ISIC-1975) and occupations (ISCO-1968). For each series, linking the information about a job episode (dates, ISIC code, ISCO code) with the matrix allowed attribution of a probability of asbestos exposure to each episode and each subject. The asbestos exposure in the two series was compared by the kappa reproducibility coefficient. RESULTS: The analysis concerned 425 questionnaires. There was at least one difference in the code for either activity sector (ISIC) or occupation (ISCO) in half the episodes (50.2%). The exposure status estimated by the job-exposure matrix did not change between the series for 84.7% of the subjects. The kappa coefficient was 0.64 for all questionnaires, 0.70 when the questionnaire was coded twice by the same coder, and 0.62 when coded by two different coders. CONCLUSIONS: Despite intra- and inter-differences between coders, the coding of job episodes for the ESPACES study appears satisfactory and hence indicates that the assessment of the subjects' asbestos exposure was assessed without major distortions. This study underlines the usefulness of employing coders specifically trained for this technique.

Asbestos↗

PubMed1984

Neural coding of complex sounds: speech.

The studies that we have reviewed here demonstrate that a temporal-place code can represent fine details in the spectra of vowels and stop-consonants. These features include formant frequencies, formant-frequency transitions, and pitch. On the other hand, such a phase locking-based representation may have difficulty with certain fricative consonants. Detailed format structure of vowels is present in a rate-place code at moderate stimulus levels, but is maintained at high levels only in the small population of low-spontaneous-rate fibers. A rate-place code preserves the formant structure at high stimulus levels better for stop-consonants than for vowels. Formant structure of some fricatives may be represented in a place-rate code in cases where a temporal-place code fails. Voice pitch is well preserved in a temporal code but not in a rate-place code. From this summary we must consider the possibility that the central nervous system utilizes both rate-place and temporal-place information in processing all of the relevant features of speech. This review points out a number of issues that currently confronts us in the coding of complex stimuli. We conclude by briefly summarizing these issues. First, we must attempt to clarify the role of the low-spontaneous-rate, high-threshold fibers in the representation of speech at high-stimulus levels. A second major question that must be addressed is the role of the cochlear efferents in the peripheral encoding of speech, especially in the presence of background noise. Closely related to the role of the efferents may be the role of the middle ear muscles. Finally, if we are to seriously consider a temporal-based code for speech, we must develop quantitative hypotheses about how spectral information might be extracted from temporal patterns in the central nervous system with real neural "hardware."

Electrophysiology↗

PubMed2002

Self-reported awareness and use of the International Classification of Diseases coding of inflammatory bowel disease services by Ontario physicians.

RATIONALE: Population and health services research can be performed by linkage analysis of administrative data. However, the robustness of study results is determined by the accuracy of the diagnostic coding. OBJECTIVES: To estimate the awareness, use and accuracy of the International Classification of Diseases, Ninth Revision (ICD-9) coding by physicians providing services for patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS: All Ontario gastroenterologists and a 10% random sample of internists, pediatricians, pediatric or general surgeons, and family physicians were surveyed by postal questionnaire to estimate the frequency and 95% CI of using codes 555 or 556 when billing for CD- and UC-related services, respectively. c2 tests were used for between-group comparisons. RESULTS: Of the physicians who were surveyed, 67.7% (416 of 614) responded; 258 of 391 (66%) who were still practising in Ontario saw patients with inflammatory bowel disease (IBD), and 54% had more than 10 IBD patients; 86.5% (95% CI 82.4% to 90.6%) were familiar with ICD-9 codes, and 91.4% (95% CI 88.1% to 95.6%) used the codes 555 (CD) or 556 (UC) for billing. Rates of ICD-9 use did not differ by sex but were used more frequently by those graduating after 1981 (P<0.02). Gastroenterologists used ICD-9 IBD codes 555 or 556 significantly more often than all other physicians (P=0.001). Most (more than 75%) Ontario physicians used ICD-9 IBD codes always or frequently when billing for IBD-related services. Few (10%) used these codes to bill for non-IBD-related problems. CONCLUSIONS: These data suggest that there is acceptable use and accuracy of ICD-9 diagnostic coding for CD and UC services - comparable with results from studies of other diseases. Administrative data may thus be used to undertake epidemiological studies in IBD in Ontario.

Awareness↗

PubMed2005

Coding of stroke and stroke risk factors using international classification of diseases, revisions 9 and 10.

BACKGROUND AND PURPOSE: Surveillance is necessary to understand and meet the future demands stroke will place on health care. Administrative data are the most accessible data source for stroke surveillance in Canada. The International Classification of Diseases, 10th revision (ICD-10) coding system has potential improvements over ICD-9 for stroke classification. Our purpose was to compare hospital discharge abstract coding using ICD-9 and ICD-10 for stroke and its risk factors. METHODS: We took advantage of a switch in coding systems from ICD-9 to ICD-10 to independently review stroke patient charts. From time periods April 2000 to March 2001, 717 charts, and from April 2002 to March 2003, 249 charts were randomly selected for review. Using a before-and-after time period design, the accuracy of hospital coding of stroke (part I) and stroke risk factors (part II) using ICD-9 and ICD-10 was compared. We used careful definitions of stroke and its types based on ICD-9 using the fourth and fifth digit modifier codes. RESULTS: Stroke coding was equally good with ICD-9 (90% [CI95 86 to 93] correct) and ICD-10 [92% (CI95 88 to 95 correct) with ICD-10. There were some differences in coding by stroke type, notably with transient ischemic attack, but these differences were not statistically significant. Atrial fibrillation, coronary artery disease/ischemic heart disease, diabetes mellitus, and hypertension were coded with high sensitivity (81% to 91%) and specificity (83% to 100%). ICD-10 was as good as ICD-9 for stroke risk factor coding. CONCLUSIONS: Passive surveillance using administrative data are a useful tool for identifying stroke and its risk factors using both ICD-9 and ICD-10.

Aged↗

PubMed2005

Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes.

OBJECTIVES: To determine the accuracy of mild traumatic brain injury (TBI) case ascertainment using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes proposed by the Centers for Disease Control and Prevention (CDC) in a 2003 Report to Congress. METHODS: This was a prospective cohort study of all patients presenting to an urban academic emergency department (ED) over six months in 2003. A real-time clinical assessment of mild TBI was compared with the ICD-9 codes assigned after ED or hospital discharge for a determination of sensitivity and specificity. RESULTS: Of the 35,096 patients presenting to the ED, 516 had clinically defined mild TBI and 1,000 were assigned one or more of the mild TBI ICD-9 codes proposed by the CDC. The sensitivity of these codes was 45.9% (95% confidence interval [95% CI] = 41.3% to 50.2%) with a specificity of 97.8% (95% CI = 97.6% to 97.9%). CONCLUSIONS: The identification of mild TBI patients using retrospectively assigned ICD-9 codes appears to be inaccurate. These codes are associated with a significant number of false-positive and false-negative code assignments. Mild TBI incidence and prevalence estimates using these codes should be interpreted with caution. ICD-9 codes should not replace a clinical assessment for mild TBI when accurate case ascertainment is required.

Adult↗

PubMed1999

Randomized study of CODE versus alternating CAV/EP for extensive-stage small-cell lung cancer: an Intergroup Study of the National Cancer Institute of Canada Clinical Trials Group and the Southwest Oncology Group.

PURPOSE: To determine whether an intensive weekly chemotherapy regimen plus thoracic irradiation is superior to standard chemotherapy in the treatment of extensive-stage small-cell lung cancer (ESCLC). PATIENTS AND METHODS: Patients with ESCLC were considered eligible for the study if they were younger than 68 years, had a performance status of 0 to 2, and were free of brain metastases. Patients were randomized to receive cisplatin, vincristine, doxorubicin, and etoposide (CODE) or alternating cyclophosphamide, doxorubicin, vincristine/etoposide and cisplatin (CAV/EP). Consolidative thoracic irradiation and prophylactic cranial irradiation were given to patients responding to CODE and according to investigator discretion on the CAV/EP arm. RESULTS: The fidelity of drug delivery on both drug regimens was equal, and more than 70% of all patients received the intended protocol chemotherapy. Although rates of neutropenic fever were similar, nine (8.2%) of 110 patients on the CODE arm died during chemotherapy, whereas one (0.9%) of 109 patients died on the CAV/EP arm. Response rates after chemotherapy were higher (P =.006) with CODE (87%) than with CAV/EP (70%). However, progression-free survival (median of 0.66 years on both arms) and overall survival (median, 0.98 years for CODE and 0. 91 years for CAV/EP) were not statistically different. CONCLUSION: The CODE regimen increased two-fold the received dose-intensity of four of the most active drugs in small-cell lung cancer compared with the standard CAV/EP regimen while maintaining an approximately equal total dose. Despite supportive care (but not routine prophylactic use of granulocyte colony-stimulating factor), there was excessive toxic mortality with the CODE regimen. The response rate with CODE was higher than that of CAV/EP, but progression-free and overall survival were not significantly improved. In view of increased toxicity and similar efficacy, the CODE chemotherapy regimen is not recommended for treatment of ESCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2002

Self-focusing hidden bar code.

A new type of diffractive optical bar code produced by computer-generated holographic technology is proposed. The message in the proposed bar code is hidden in the diffracted light of the bar code element and can be read from the first diffraction order. In contrast to the conventional hidden bar code, which needs a lens to focus the diffracted light, the proposed hidden bar code has a property of self-focusing. This self-focusing ability is achieved by modulating a function of the Fresnel zone plate into the bar code format. Consequently, the read-out process for the information in this hidden bar code avoids the use of a lens. Experiments have shown the feasibility of the proposed bar code and confirmed that it can perform better than the conventional hidden bar code.

Journal Article↗