Coding rules for uncertain and "ruled out" diagnoses in ICD-10 and ICD-11.

Autor: Atolagbe OO; Health Information Management Department, University of California Davis Health, Sacramento, CA, USA., Romano PS; Departments of Internal Medicine and Pediatrics, and Center for Healthcare Policy and Research, University of California Davis Health, Sacramento, CA, USA. psromano@ucdavis.edu., Southern DA; Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada., Wongtanasarasin W; Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand., Ghali WA; Office of Vice President of Research, University of Calgary, Calgary, AB, Canada.
Jazyk: angličtina
Zdroj: BMC medical informatics and decision making [BMC Med Inform Decis Mak] 2024 Sep 27; Vol. 21 (Suppl 6), pp. 386. Date of Electronic Publication: 2024 Sep 27.
DOI: 10.1186/s12911-024-02661-6
Abstrakt: The International Classification of Diseases, 11th Revision (ICD-11) has significantly improved the ability to navigate coding challenges beyond prior iterations of the ICD. Commonly encountered sources of complexity in clinical documentation include coding of uncertain and "ruled out" diagnoses. Assessing official international guidelines and rules, this paper documents extensive variation across countries in existing practices for coding and reporting unconfirmed and "ruled out" clinical concepts in ICD-10 (and modifications thereof). The design of ICD-11 is intended to mitigate these coding challenges by introducing postcoordination, expanding the range of codable clinical concepts, and offering clearer guidance in the ICD-11 Reference Guide. ICD-11 offers substantial progress towards more precise capture of uncertain and "ruled out" diagnoses, including international consensus on coding rules for these historically challenging clinical concepts. However, we identify the need for further clarification of the concepts of "provisional diagnosis" and "differential diagnosis."
(© 2024. The Author(s).)
Databáze: MEDLINE
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