A review of clinical coding accuracy at University College Hospital, Ibadan, Nigeria

Abstract

Background: Clinical coding is an important aspect of health information management and the processmust be accurate as mistakes in coding can lead to multiplication of errors in patient care and clinicalresearch. Coding accuracy measures the level of agreement between the disease classification systemscode(s) and the selected code(s) recorded in the discharged record by the Coder. The integrity of datafrom clinical coding depends fundamentally on the quality of clinical documentation, availability ofdischarge summary in the patient record and Coders ability. The study examine accuracy in terms oflevels of agreement and including completeness of codes and factors that may contribute to error incoding. Methods: A sample of 2000 discharged patients’ health records that had been previously codedwas randomly selected and re-coded by an experienced Clinical coder. Data extraction format was usedto extract information on coding accuracy and factors that could lead to errors in coding. Data analyseswere done using SPSS Version 25 with focus on descriptive statistics. Results: Coders in the clinicalcoding unit of the hospital are Health Information Management Professionals, with no formal training incoding but, on-the-job training. Discharge summary is not completed in most discharged patients’ healthrecords therefore, coders read through records to select diagnoses for coding. Conclusion: Absence ofdischarge summary could be counterproductive to clinical coding process in the hospital, resulting totime wasting, incomplete coding and coding error. Clinicians are therefore advised to write dischargedsummary in order to reduce coding error. Clinical Coding should be seen as an area of specialization inHIM hence, coders should be specially trained and encouraged to attend continuing professional development programme related to clinical coding. The Department of Health Records should retainexperienced clinical coders and the clinical coding unit should be well-staffed to reduce work-load thatcould increase error in coding.Keywords: Clinical coding; Clinicians; Coding accuracy; Diagnoses; Health Information ManagementProfessionals; and Tertiary hospital