Concerns with Clinical Coding

Clinical coding is the process by which procedures are translated into a code which is used for proper “hospital reimbursement.” [1] Due to the nature of the job and its emphasis on recall of possibly thousands of alphanumeric codes, it would seem as though a dedicated position within the hospital would be the best person to task with carrying out coding. However, in many cases, physicians are the ones tasked with coding for their own procedures. Even when this isn’t the case, the coders that are in charge of translating chart information into alphanumerical coding are often given an incomplete picture; whether from incomplete physician notation or incorrect information, leading to errors that affect patients and institutions financially. [2]

On the surface, it would make sense to have surgeons code for their own procedures in order to maintain a high degree of precision in detailing exactly what was performed intra-operatively. However, the heavy workload that healthcare professionals face now, especially with the move to electronic health records, makes accurate and precise coding a much more challenging operation. [3] Over a sample of 30,127 patients, some 15,402 patients had at least one change made to their medical records after audit, a shocking 51%, with a further 13% and 12% respectively being changes made to primary diagnoses or operations. [4] This degree of error in a financially high stakes area raises red flags about the implications that these errors have made on patients and their financial wellbeing.

The stress that surgeons face is only exacerbated by the expectation to code for procedures on top of actually performing them. Additionally, with heightened precision in coding for physicians comes an extended amount of time required to do so, extending the already severe shift load that surgeons are expected to take on. This creates an unrealistic expectation to perform surgery, complete documentation for the patient, and code for the operations more precisely without proper downtime. Trying to remedy this is also fraught with difficulty, with dedicated coders being subject to physician error, missing information, or unfamiliar terminology without the knowledge to bridge the gaps. [2]

Oftentimes pressing issues are also the most difficult to find a meaningful solution to, and misrepresentative coding is no different. By onboarding clinical coding personnel in hospitals, and attempting to bridge the gap in communication, documentation, and accountability between surgeons and coders, hospitals can more accurately bill patients, leading to better financial outcomes on both sides of the operating table.

Reviewed by: Benji Forman

Designed by: Maziar Salartash

References:

[1] Haliasos N, Rezajooi K, O'neill KS, Van Dellen J, Hudovsky A, Nouraei S. (2010) Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit. Br J Neurosurg. 24(2):191-5. doi: 10.3109/02688690903536595. PMID: 20210533.

[2] Tang, K. L., Lucyk, K., & Quan, H. (2017). Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study. CMAJ open, 5(3), E617–E622. https://doi.org/10.9778/cmajo.20170036

[3] Ball, C. G., & McBeth, P. B. (2021). The impact of documentation burden on patient care and surgeon satisfaction. Canadian journal of surgery. Journal canadien de chirurgie, 64(4), E457–E458. https://doi.org/10.1503/cjs.013921

[4] Nouraei, S. A. R. BChir, PhD, MRCS*,†,‡; Hudovsky, A. BSc§; Frampton, A. E. MB, MRCS¶; Mufti, U. MB, MRCS‖; White, N.B. MB, FRCP, FRCS**; Wathen, C. G. MB, FRCP††; Sandhu, G. S. MD, FRCS‡; Darzi, A. KBE, FRS, FRCS‡‡ (2015). A Study of Clinical Coding Accuracy in Surgery: Implications for the Use of Administrative Big Data for Outcomes Management. Annals of Surgery 261(6):p 1096-1107. | DOI: 10.1097/SLA.0000000000000851