Level of agreement between medical record and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients

Abstract

This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Pre‐existing mental health disorders in patients admitted to the intensive care unit: A systematic review and meta‐analysis of prevalence

“…Clinicians acknowledge that the accurate diagnosis of mental health disorders is fraught with difficulty (Hyman, 2010), both in a clinical or a research context. Traditional methods for identifying pre‐existing mental health disorders in administrative data sets, as used by most studies in this review, often fail to identify a significant percentage of patients (Colvin et al., 2013; Nguyen et al., 2019). Manual review of patient progress notes, as used in the study by van der Kuur et al.…”

“…Manual review of patient progress notes, as used in the study by van der Kuur et al. (2019), has been demonstrated to be a more accurate, although far more labour‐intensive, method (Kim et al., 2012; Nguyen et al., 2019). However, none of these techniques can be easily translated into clinical practice.…”

“…Most included studies that relied on databases or administrative datasets to identify pre‐existing mental health disorders. These types of datasets have been suggested to miss up to half of all pre‐existing mental health disorders (Colvin et al., 2013; Nguyen et al., 2019), resulting in a potentially significant underestimation of the prevalence rate. Furthermore, as previously discussed, the prevalence rates reported by the largest three studies (Abrams et al., 2010a, 2010b; Wunsch et al., 2014) were likely to be underestimates as a result of their populations and definitions of a pre‐existing mental health disorder.…”

The role of health classifications in health information management

“…Researchers rely on the coded data for much of their work and are therefore interested in the integrity of the data and the relevance of the classifications to their sphere of interest. Several articles in this Virtual Special Issue report on studies to reconcile the information in the medical record or in other databases with the coded data held in admitted patient datasets (Handley and Emsley, 2020; Murray et al, 2017; Nguyen et al, 2019; Sveticic et al, 2020; Trinh et al, 2017, 2018). They identify a range of issues associated with the coded data, including that in some cases conditions are not being coded and in others that clinical codes do not provide the specificity needed for good research.…”

Clinical coding and the quality and integrity of health data

“…Given that clinical coders are governed by guidelines and standards that limit the assignment of codes in certain circumstances, very important questions are raised by these papers. Australian authors, Nguyen et al (2019), studied the level of agreement between documentation in the medical records and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients. These authors concluded that despite documentation in the medical record, these conditions are not always coded, rendering incomplete the administrative databases on which epidemiologists and other researchers rely.…”