Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions

Abstract

Background: Health records are the basis of clinical coding. In Portugal, relevant diagnoses and procedures are abstracted and categorised using an internationally accepted classification system and the resulting codes, together with the administrative data, are then grouped into diagnosis-related groups (DRGs). Hospital reimbursement is partially calculated from the DRGs. Moreover, the administrative database generated with these data is widely used in research and epidemiology, among other purposes. Objective: To explore the perceptions of medical coders (medical doctors) regarding possible problems with health records that may affect the quality of coded data. Method: A qualitative design using four focus groups sessions with 10 medical coders was undertaken between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed from the literature and authors’ expertise. The focus groups sessions were taped, transcribed and analysed to elicit themes. Results: There are several problems, identified by the focus groups, in health records that influence the coded data: the lack of or unclear documented information; the variability in diagnosis description; “copy & paste”; and the lack of solutions to solve these problems. Conclusion and implications: The use of standards in health records, audits and physician awareness could increase the quality of health records, contributing to improvements in the quality of coded data, and in the fulfilment of its purposes (e.g. more accurate payments and more reliable research).

Auditing the Accuracy of Medical Diagnostic Coding based on International Classification of Diseases, Tenth Revision

“…Medical records affect the coded data for a range of reasons, including unclear documentation and variations in the description of diagnoses. Therefore, the use of these standards can be effective in diagnostic coding and audits to improve the quality of coded data (28). The present study also confirmed the impact of non-compliance with diagnostic principles (31.6%) and medical records legibility (17.2%) on the given codes.…”

Classification performance of administrative coding data for detection of invasive fungal infection in paediatric cancer patients

“…First, harmonisation of clinical EORTC/MSG definitions with existing Australian Coding Standards may help safeguard accurate detection of IFI in the coded data by reducing ascertainment of false positive cases (for example, our high number of false positive cases [N = 38] coded as 'candidiasis of other sites' [code B37.88]). In fact, recent qualitative research proposes the use of Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) codes in electronic health records as a more granular tool to standardise terminology and facilitate clinical coding of complex diseases [25,31,32]. Second, ensuring that chart documentation is complete, legible and streamlined will ensure clinical coders have sufficient access to the data required to assign the appropriate IFI code(s) [25,33,34].…”

Findings from the Health Information Management Section of the 2020 International Medical Informatics Association Yearbook

“…Methods to assess the quality differed across studies. One approach to assessing quality involved focus groups and interviews of Health Information Managers and coders [1,2]. This qualitative research found problems in completeness, accuracy, and consistency in coding.…”