Reliability of Medical Diagnosis with International Classification of Diseases 10th Version in 2011

Document Type : Original Article

Authors
Jahanpour Alipour 1
Afsaneh Karimi 2
Leila Erfannia 2
Mahnaz Shahrakipour 3
Mohammad Hossein Hayavi Haghighi 4
Abbas Kadkhoda 5
Kobra Mirshekar 5
1 Lecturer, Health Information Technology, School of Paramedical, Zahedan University of Medical Sciences, Zahedan AND PhD Student, Health Information Management, Tehran University of Medical Sciences, Tehran, Iran
2 Lecturer, Health Information Technology, School of Paramedical, Zahedan University of Medical Sciences, Zahedan, Iran
3 Assistant Professor, Statistics and Epidemiology, School of Health, Zahedan University of Medical Sciences, Zahedan, Iran
4 Lecturer, Health Information Technology, School of Paramedical, Bandarabbas University of Medical Sciences, Bandarabbas, Iran
5 Medical Records, Zahedan University of Medical Sciences, Zahedan, Iran 1392
Abstract
Introduction: Reliability of diagnoses coding is essential for the use of data in national and international
levels. The present study compared the reliability of diagnoses coding with 10th version of the
International Classification of Diseases (ICD-10) between the two groups of coders.
Methods: Two hundred and forty five priorly coded medical records from five public hospitals affiliated
to Zahedan University of Medical Sciences, Iran were re-coded by hospital coders and researcher in the
first half of 2011. Data collection was done through a checklist. Validity of this instrument was confirmed
by the experts. Intra-rater reliability (reliability of coder) and inter-rater reliability (reliability of prior
codes with researcher codes or current codes of coder with researcher codes) were assessed in different
level of diagnoses using Cohen’s Kappa.
Results: In the most cases, inter-rate reliability was almost perfect. Only in level of first three character of
principle diagnoses value of Kappa was moderate (K = 0.52). Furthermore, external reliability in most
cases was upper than moderate. Only reliability of codes dedicated by researcher and prior codes on
medical records in the fifth character of principle diagnosis was low (K = 0.18), the fourth character of the
first other diagnosis was moderate (K= 0.60), and also in chapter level of the third, the other diagnosis
were moderate (K= 0.54). Furthermore, Kappa value (between coder and researcher) for principle diagnosis
in the first three character was moderate (K = 0.47), and in the fifth character level was low (K = 0.18).
Conclusion: Reliability of diagnoses coding was appropriate in level of chapter and the fourth character
and was not appropriate in three levels of the first and fourth characters. This could be resulted from error
selection of principle diagnosis in multiple-coding and negligence of coder to level of specificity in
coding. Thus, implementation of in-service educational programs for coders seems essential

Keywords

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Health Information Management
Volume 10, Issue 1
Spring 2014
Pages 26-34