Audit: the importances of accurate coding
Aims
To evaluate the accuracy of clinical coding amongst medical inpatients at a university teaching hospital.
Background
Coding is the translation of diagnostic information into alphanumeric codes. Accurate coding not only is important for financial reasons, but also furnishes high-quality data to commissioners and providers to understand the healthcare burden and needs of their local population. A primary diagnosis is coded alongside multiple secondary diagnoses (usually chronic problems). In many hospitals, including ours, coding is generated from the electronic discharge summary (EDS). Based on coding, patients are assigned a healthcare resource group (HRG) and this dictates a proportion of hospital funding.
Methods
25 patients admitted under the respiratory team between August and September 2013 were randomly selected. These patients had been coded using the EDS. Patients were re-coded using the written notes (gold standard). Errors when using the EDS were identified and implementations made. A re-audit was carried out in June 2014.
Results
The initial audit identified a total of 33 errors. The errors were split into primary and secondary diagnosis, coder and non-coder. Table 1 illustrates this.
For coder errors, the diagnosis was clear on the EDS but coded incorrectly or omitted by the coder. For non-coder errors, the diagnosis was unclear or omitted from the EDS. All errors in secondary diagnosis were due to omission. Primary diagnostic errors were generally due to lack of clarity on the EDS by doctors or misjudgement by the coders. A departmental meeting was held to educate all team members and a list of common primary diagnoses given to all doctors to improve clarity on the EDS.
No errors in secondary diagnosis made a difference to the HRG but, in three cases, a change to the primary diagnosis altered the HRG: £2,776 had been lost to the trust. Given the cost implications and high proportion of incorrect primary diagnoses, this was re-audited. In the re-audit, three out of 25 primary diagnoses were incorrect.
Conclusions
This audit highlights that errors in clinical coding are common. However, this can be improved by raising awareness, particularly amongst junior doctors involved in preparing the EDS. Doctors need to, where possible, outline a clear primary diagnosis and mention all secondary diagnoses on the EDS. The format of the EDS should be tailored towards this. Regular meetings between clinicians and coders would be useful to further improve the accuracy of the coding process.
Conflict of interest statement
There are no conflicts of interest.
Declaration of Interest
- © Royal College of Physicians 2015. All rights reserved.
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