CODING CLINICAL INFORMATION - ANALYSIS OF CLINICIAN USING COMPUTERIZED CODING

Data are presented of a controlled experiment with a computerized brow sing and encoding tool. Eighteen practicing clinicians extracted medic al concepts from two narrative exercise cases using two approaches, tr aditional and computer-assisted use of ICD-9. Our results indicate tha t by using a computerized coding tool the completeness of coding can b e improved by up to 55%, that by enforcing mandatory as opposed to opt ional modifier codes results in lower rates of incomplete coding (0 an d 55%, respectively), higher rates of correct coding (41 to 92%) and n o change in incorrect code, and that manual coding takes twice as long than coding with the help of the computerized coding tool. Clinicians need 59% more time for processing the whole set of codes than is sugg ested by the sum of individual codes. We conclude that the use of a co mputerized coding tool can save time and result in higher quality code s. However, the real time spent on coding may be underestimated when l ooking at individual coding times, instead of the whole task of proces sing a clinical scenario.