The impact of three discharge coding methods on the accuracy of diagnostic coding and hospital reimbursement for inpatient medical care

International Journal of Medical Informatics
Rosy TsopraJeremy C Wyatt

Abstract

Coding of diagnoses is important for patient care, hospital management and research. However coding accuracy is often poor and may reflect methods of coding. This study investigates the impact of three alternative coding methods on the inaccuracy of diagnosis codes and hospital reimbursement. Comparisons of coding inaccuracy were made between a list of coded diagnoses obtained by a coder using (i)the discharge summary alone, (ii)case notes and discharge summary, and (iii)discharge summary with the addition of medical input. For each method, inaccuracy was determined for the primary, secondary diagnoses, Healthcare Resource Group (HRG) and estimated hospital reimbursement. These data were then compared with a gold standard derived by a consultant and coder. 107 consecutive patient discharges were analysed. Inaccuracy of diagnosis codes was highest when a coder used the discharge summary alone, and decreased significantly when the coder used the case notes (70% vs 58% respectively, p < 0.0001) or coded from the discharge summary with medical support (70% vs 60% respectively, p < 0.0001). When compared with the gold standard, the percentage of incorrect HRGs was 42% for discharge summary alone, 31% for coding with case notes, and ...Continue Reading

Citations

Sep 15, 2020·The Journal of International Medical Research·Yawen LiYuchen Gao
May 7, 2019·Frontiers in Medicine·Michela AssaleFederico Cabitza
Oct 10, 2020·European Journal of Surgical Oncology : the Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology·Shaun SelvaduraiShahid A Khan
Apr 14, 2021·Health Information Management : Journal of the Health Information Management Association of Australia·Nafiseh HosseiniSaeid Eslami
May 27, 2021·The International Journal of Health Planning and Management·Nafiseh HosseiniSaeid Eslami
Oct 4, 2021·BMC Medical Informatics and Decision Making·Rosy TsopraAnita Burgun
Aug 11, 2020·Seizure : the Journal of the British Epilepsy Association·Johanna W BunschotenRoland D Thijs

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