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In Case of Emergency - Are ICD-10 Codes Enough?

Christian Juhra, Johannes Schenkel, Jürgen Albert, Norbert Butz, Judith Born

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Abstract

In an acute emergency, the knowledge of the patient's medical history, allergies, implants, and medication can be crucial. ICD-10 code to document medical diagnoses alone often does not contain enough information. Our comparison of 388 documented diagnoses (ICD-10 codes as well as free text) showed that almost 20% of all coded ICD-10 codes contained less information than the documented free text. Thus, if using ICD-10 codes, free text diagnoses must be a necessary item in the upcoming German Medical Emergency DataSet.

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What this paper is about

In an acute emergency, the knowledge of the patient's medical history, allergies, implants, and medication can be crucial. ICD-10 code to document medical diagnoses alone often does not contain enough information. Our comparison of 388 documented diagnoses (ICD-10 codes as well as free text) showed that almost 20% of all coded ICD-10 codes contained less information than the documented free text. Thus, if using ICD-10 codes, free text diagnoses must be a necessary item in the upcoming German Medical Emergency DataSet.

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Available abstract

In an acute emergency, the knowledge of the patient's medical history, allergies, implants, and medication can be crucial. ICD-10 code to document medical diagnoses alone often does not contain enough information. Our comparison of 388 documented diagnoses (ICD-10 codes as well as free text) showed that almost 20% of all coded ICD-10 codes contained less information than the documented free text. Thus, if using ICD-10 codes, free text diagnoses must be a necessary item in the upcoming German Medical Emergency DataSet.

Key concepts: Medical diagnosis, Diagnosis code, ICD-10, Medical emergency, Emergency department, German, Medical classification, Medical information

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