Towards the Development of a Web Support System for Improving Accuracy in Coding Discharge Diagnosis

The practice of coding morbidity data using international standard diagnostic classifications has become increasingly important and recognized as a difficult and timeconsuming task. Clinical coders/physicians assign codes to each patient episode based on their interpretation of the available case notes or the electronic patient record systems. Therefore, accurate coding depends on the legibility of the case notes and on the coders' understanding of medical terminology. Several studies have indicated poor reproducibility of clinical coding. To support physicians, in the coding of diagnoses and procedures using ICD 9th revision, Clinical Modifications (ICD-9-CM), and in identifying the main condition to be filled in Hospital Discharge Records, the SISCO.web service is proposed. The service has the aim of improving the accuracy of coding by using the combination of NLP algorithms, controlled vocabularies mapped to ICD-9-CM, as well as coding-rules and a decision trees for the identification of the main condition.