Mental, emotional, and behavioral disorders are chronic pediatric conditions, and their prevalence has been on the rise over recent decades. Affected children have long-term health sequelae and a decl...
We aimed to evaluate the accuracy of coding related to pediatric mental, emotional, and behavioral disorders in a large integrated health care system's electronic health records (EHRs) and compare the...
Medical records of 1200 member children aged 2-17 years with at least 1 clinical visit before the COVID-19 pandemic (January 1, 2012, to December 31, 2014, the ICD-9-CM coding period; and January 1, 2...
The overall agreement between the identification of mental, behavioral, and emotional conditions using diagnosis codes compared to medical record abstraction was strong and similar across the ICD-9-CM...
Diagnostic codes are quite reliable for identifying selected childhood mental, behavioral, and emotional conditions. The findings remained similar during the pandemic and after the implementation of t...
The use of routine data will be essential in future healthcare research. Therefore, harmonizing procedure codes is a first step to facilitate this approach as international research endeavour. An exam...
We included the existing surgical procedure coding systems of five European countries (France, Germany, Italy, Spain, and the United Kingdom [UK]). In an iterative process, country specific codes were...
A total number of 153 SALT (Staphylococcus aureus Surgical Site Infection Multinational Epidemiology in Europe) codes from 10 specialties were assigned to 15,432 surgical procedures. Almost 4000 (26%)...
Mapping country-specific codes procedure codes onto to a limited number of coherent, internally and externally validated codes proofed feasible. The resultant SALT procedure code gives the opportunity...
The study was registered at clinicaltrials.gov under NCT03353532 on November 27...
Alcohol (AC) and nonalcohol-associated cirrhosis (NAC) epidemiology studies are limited by available case definitions. We compared the diagnostic accuracy of previous and newly developed case definiti...
We randomly selected 700 hospitalizations from the 2008 to 2022 Canadian Discharge Abstract Database with alcohol-associated and cirrhosis-related International Classification of Diseases 10th revisio...
Electronic medical records were available for 671 admissions; 252 had confirmed AC and 195 NAC. Compared to previous AC definitions, the newly developed algorithm selecting for the AC code, alcohol-as...
New case definitions show enhanced accuracy for identifying hospitalizations for AC and NAC compared to previously used approaches....
The purpose of this study was to examine coding changes using the International Classification of Diseases (ICD) after the transition from ICD-9 to ICD-10. We studied a national cohort of emergency de...
In Denmark, data on hospital contacts are reported to the Danish National Patient Registry (DNPR). The ICD-10 main diagnoses from the DNPR are often used as proxies for mental disorders in psychiatric...
All main diagnoses from outpatients attending the Psychiatric Services of the Central Denmark Region from 2013 to 2021 (n = 100,501 unique patients) were included in the analyses. The stability of the...
While the proportion of psychiatric outpatients with diagnoses from some ICD-10 subchapters changed statistically significantly from the DNPR2 to the DNPR3, the changes were small in absolute terms (e...
The change from the DNPR2 to the DNPR3 is unlikely to pose a substantial threat to the validity of most psychiatric research at the diagnostic subchapter level....
Transgender people experience extreme rates of violence and the electronic medical record (EMR) remains a mostly untapped resource to study the medical sequelae of such experiences....
To develop and test a method for identifying experiences of violence using EMR data....
Cross-sectional study utilizing EMR data....
Transgender and cisgender people seen at a regional referral center in Upstate New York....
We tested the utility of keyword searches and structured data queries to identify specific types of violence at various ages and in various contexts among cohorts of transgender and cisgender people. ...
Of the transgender cohort, 47% had experienced some type of violence versus 14% of the cisgender cohort (χ 2P value <0.001). Keywords were significantly more effective than structured data at identify...
Transgender people experience extreme amounts of violence throughout their lives, which is better identified and studied using keyword searches than structured EMR data. Policies are urgently needed t...
Diagnoses entered by general practitioners into electronic medical records have great potential for research and practice, but unfortunately, diagnoses are often in uncoded format, making them of litt...
The framework of diagnostic codes was developed based on input from local stakeholders and consideration of epidemiological data. After pre-testing, the framework contained 105 diagnostic codes, which...
The sample consisted of 26,980 LoFT and in 56.3% no code could be assigned because it was not a specific diagnosis. The most common diagnostic codes were, 'dorsopathies' (3.9%, a code covering all typ...
The coding framework was characterised by a subset of very frequent and highly reliable diagnostic codes, which will be the most valuable targets for training NLP models for automated disease classifi...
The allocation of healthcare resources is reliant upon accurate information generated through clinical coding. Several factors contribute to coding inaccuracies, one of which is interpreting medical d...
Despite minimal coding and billing training, surgeons are frequently tasked with both in clinical practice. This often results in denials for reimbursement based on incorrect or insufficient documenta...
Hospital billing data were analyzed for a 4-year period (2018 to 2021) to determine the CPT code denials with the largest overall cost. The denials were then stratified according to payor, reason for ...
A total of 8,833 denials representing $11,009,108 in billing were noted during the study period. The CPT code 44970 (laparoscopic appendectomy) was the code associated with the largest financial impac...
This is the first study to systematically evaluate a pathway for using denial data to improve collections for work performed at a high-volume academic pediatric surgery practice. Using this methodolog...
Diagnosis can often be recorded in electronic medical records (EMRs) as free-text or using a term with a diagnosis code. Researchers, governments, and agencies, including organisations that deliver in...
This cross-sectional data quality study used de-identified EMR data from 84 general practices in Victoria, Australia. Data represented 456,125 patients who attended one of the general practices three ...
Undercounts were evident in all six diagnoses when using coded diagnoses alone (2.57-36.72% undercount), of these, five were statistically significant. Overall, 26.4% of all patient diagnoses had not ...
In Australia clinical decision support and the reporting of aggregated patient diagnosis data to government that relies on coded diagnoses can lead to significant underreporting of diagnoses compared ...
