Correlation Between Medical Terminology Accuracy and ICD-10 Coding

A Retrospective Quantitative Study

Abstract

Background: Accurate medical terminology is essential for diagnostic documentation and forms the basis of reliable ICD-10 coding. Inconsistencies in terminology may lead to coding errors, reduced data quality, and inaccurate reimbursement for health insurance claims. Methods: This retrospective quantitative study employed a cross-sectional design at Setia Mitra Hospital. Data were analyzed to evaluate the accuracy of medical terminology in diagnosis writing, the accuracy of ICD-10 coding, and the correlation between the two variables. Results: Out of 137 outpatient diagnoses, 97 (71%) were consistent with standard medical terminology, while 40 (29%) were not. Regarding ICD-10 coding, 65 codes (47.44%) were accurate, whereas 35 (25.54%) were inaccurate. Chi-Square correlation analysis yielded a p-value of 0.276 (p > 0.05), indicating no significant association between the accuracy of medical terminology and ICD-10 coding accuracy. Conclusion: The study found no correlation between medical terminology accuracy and ICD-10 coding accuracy. These findings highlight the need for standardized documentation, continuous training, stronger coder–clinician collaboration, and routine audits to improve diagnostic and coding reliability. Future research may involve multiple facilities, inpatient data, or qualitative approaches to explore contextual factors affecting coding accuracy.