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Int J Qual Health Care. 2015 Aug;27(4):328-33. doi: 10.1093/intqhc/mzv037. Epub 2015 Jun 4.

Capturing diagnosis-timing in ICD-coded hospital data: recommendations from the WHO ICD-11 topic advisory group on quality and safety.

Author information

Department of Medicine, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia.
Departments of Internal Medicine and Pediatrics, and Center for Healthcare Policy and Research, University of California Davis, Davis, CA, USA.
Department of Community Health Sciences, University of Calgary, Calgary, Canada.
Institut Universitaire de Médecine Sociale et Préventive, Lausanne University Hospital, Lausanne, Switzerland.
Faculty of Health Care, Niederrhein University of Applied Sciences, Krefeld, Germany.
Health Council of Canada, Toronto, Canada.
Department of Psychiatry, Division of Clinical Phenomenology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
Department of Community Health Sciences, University of Calgary, Calgary, Canada Department of Medicine, University of Calgary, Calgary, Canada.



To develop a consensus opinion regarding capturing diagnosis-timing in coded hospital data.


As part of the World Health Organization International Classification of Diseases-11th Revision initiative, the Quality and Safety Topic Advisory Group is charged with enhancing the capture of quality and patient safety information in morbidity data sets. One such feature is a diagnosis-timing flag. The Group has undertaken a narrative literature review, scanned national experiences focusing on countries currently using timing flags, and held a series of meetings to derive formal recommendations regarding diagnosis-timing reporting.


The completeness of diagnosis-timing reporting continues to improve with experience and use; studies indicate that it enhances risk-adjustment and may have a substantial impact on hospital performance estimates, especially for conditions/procedures that involve acutely ill patients. However, studies suggest that its reliability varies, is better for surgical than medical patients (kappa in hip fracture patients of 0.7-1.0 versus kappa in pneumonia of 0.2-0.6) and is dependent on coder training and setting. It may allow simpler and more precise specification of quality indicators.


As the evidence indicates that a diagnosis-timing flag improves the ability of routinely collected, coded hospital data to support outcomes research and the development of quality and safety indicators, the Group recommends that a classification of 'arising after admission' (yes/no), with permitted designations of 'unknown or clinically undetermined', will facilitate coding while providing flexibility when there is uncertainty. Clear coding standards and guidelines with ongoing coder education will be necessary to ensure reliability of the diagnosis-timing flag.


condition-onset flag; diagnosis-timing indicators; hospital performance; international classification of diseases; patient safety; present-on-admission flag; world health organization

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