Health Information Management Department, University of California Davis Health, Sacramento, CA, USA.
Departments of Internal Medicine and Pediatrics, and Center for Healthcare Policy and Research, University of California Davis Health, Sacramento, CA, USA.
BMC Med Inform Decis Mak. 2024 Sep 27;21(Suppl 6):386. doi: 10.1186/s12911-024-02661-6.
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."
《国际疾病分类》第 11 版（ICD-11）在解决编码挑战方面的能力有了显著提高，超越了 ICD 以往的版本。在临床文档中，常见的复杂来源包括不确定和“排除”诊断的编码。本文评估了官方国际准则和规则，记录了在 ICD-10 中（及其修改版）对未确认和“排除”临床概念进行编码和报告的现有实践在各国之间存在的广泛差异。ICD-11 的设计旨在通过引入后置协调、扩大可编码临床概念的范围，并在 ICD-11 参考指南中提供更清晰的指导，来缓解这些编码挑战。ICD-11 在更精确地捕捉不确定和“排除”诊断方面取得了重大进展，包括对这些历史上具有挑战性的临床概念的编码规则达成了国际共识。然而，我们发现需要进一步澄清“临时诊断”和“鉴别诊断”的概念。
