Who annotated the ICD codes?

[JoakimEdin]

Prerequisites

• [X ] Put an X between the brackets on this line if you have done all of the following:
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Description

Certain cases are annotated with ICD diagnosis codes not described in the medical documentation. I hypothesize that a doctor has assigned the code but forgotten to document the diagnosis in the discharge summary. Do the doctors or secretaries assigned the ICD codes at Beth Israel Deaconess Medical Center?

[tompollard]

@JoakimEdin It's been a long time since I looked into ICD codes, but as far as I remember they are all assigned by a clinical coding team in the hospital upon discharge, based on the EHR data and notes. Clinicians do not assign the codes themselves (and if I remember rightly, the coders do not interact with the clinicians when assigning the codes).

If you are seeing codes that do not appear in the documentation directly, my guess is that the code has been assigned based on a set of coding rules (rather than the code being "forgotten" by a clinician). @alistairewj @lceli may be able to add more detail.