Discussion on Problems of Misuse of Unspecified Codes in ICD-9-CM-3

AbstractObjective. To understand the current situation of misuse of unspecified codes for surgeries and operations of ICD-9-CM-3, analyze the causes, and find solutions. Methods. All the unspecified codes for surgeries and operations are summarized in line with the ICD-9-CM-3 (2011 version) and compared with the Peking Union Medical College Hospital (PUMCH)'s existing dictionary database of coding. All codes mentioned above are searched one by one in the PUMCH's management information system of medical record home pages in 2012, the number of error codes in the search is counted and the rate of error coding is calculated. Results. Referring to the latest version of the ICD-9-CM-3, a total of 162 unspecified surgical and operational codes are screened out, in which 58 out of 162 codes exist in the dictionary database of our hospital, and 60.3% (35/58) of the codes are in error after individual retrieval. As a whole, the error rate of unspecified coding is 15.5%. The error rates of “NOS” codes and “unspecif...