Clinical and Medical Coding: A New Pathway for Automation-An Updated Review

Document Type : Original Article

Authors

1 Hospital management specialist, Northern Area Armed Forces Hospital, Saudi Arabia

2 HEALTH INFORMATICS, Northern Area Armed Forces Hospital, Saudi Arabia

3 Health Information Technician, Northern Area Armed Forces Hospital, Saudi Arabia

4 Pharmacy Technician, Northern Area Armed Forces Hospital, Hafar Albaten, Saudi Arabia

Abstract

Background: Clinical coding is a critical process in healthcare, involving the transformation of free-text medical records into structured codes using classification systems like ICD-10. This process ensures consistent and comparable clinical data, supporting healthcare planning, policy-making, and epidemiological research. Aim: This review aims to explore the evolution of automated clinical coding, evaluate the performance of state-of-the-art deep learning models, and identify key challenges and future directions for improving automated coding systems. Methods: The review synthesizes findings from 113 studies on automated clinical coding, focusing on the transition from rule-based symbolic AI to neural AI, particularly deep learning. It examines the performance of multi-label classification models, the integration of knowledge-based approaches, and the challenges of handling long documents, imbalanced data, and terminology changes. The review also highlights the importance of human-in-the-loop learning and explainability in automated systems.
Results: Deep learning models, particularly transformer-based architectures like BERT, have achieved Micro-F1 scores of 58-60% on benchmark datasets like MIMIC-III. However, challenges such as handling infrequent codes, processing long documents, and incorporating symbolic reasoning persist. Hybrid approaches combining symbolic and neural AI show promise, as do knowledge-augmented deep learning methods. Studies also emphasize the need for high-quality datasets, explainability, and adaptability to new coding systems like ICD-11.
Conclusion: Automated clinical coding has made significant progress but remains a complex task requiring further research. Future directions include integrating symbolic reasoning, improving explainability, and developing more representative datasets. Collaboration between AI researchers and clinical coding experts is essential to advance the field.

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