COMPUTER-PROMPTED DIAGNOSTIC CODES

Background. The purpose of this study uas to develop and evaluate a co mputer system that would translate patient diagnoses noted by a physic ian into appropriate International Classification of Diseases, 9th Rev ision, Clinical Modification (ICD-9-CM) codes and maintain a patient-s pecific up-to-elate problem list. Methods. The intervention consisted of a computerized list (dictionary) of diagnoses, including practice-s pecific synonyms and abbreviations, linked to their corresponding ICD- 9-CM codes. To record the diagnoses for the office visit before the in tervention, physicians used International Classification of Health Pro blems in Primary Care (ICHPPC-2) codes. After the intervention, physic ians used their own words or checked previously identified diagnoses o n tile computer-generated problem list. The computer then identified t he correct ICD-9-CM code. Accuracy of coding was compared before and a fter the new computerized system was implemented. Results. Visits in w hich all diagnoses matched increased from 58% to 76% (P<.001) with use of the computer system. Visits in which no computer diagnoses matched the chart decreased from 22% to 8% (P<.001). Errors of omission decli ned from 38% to 18% (P<.001). Errors of commission decreased from 19% to 11% (P=.006). Overall accuracy increased from 62% to 82% (P<.001). Conclusions. Outpatient medical diagnosis coding can be simplified and accuracy improved by using a computerized dictionary of practice-spec ific diagnoses and synonyms linked to appropriate ICD-9-CM codes. Such a system provides a computer-generated problem list that accurately r eflects tile chart and assists with prompted coding on subsequent visi ts.