The quality of burns coding. Compliance with standards and the effects on clinical data

Coded burns cases in two NSW public acute care facilities were reviewed to determine 1. the degree of compliance with Australian Coding Standards (ACS) relating to burns separations 2. the relationship between coding errors and poor quality documentation and 3. the impact of coding errors on ANDRG allocation. Despite high compliance with specific aspects of the ACS, coding errors occurred in 89% of cases. The ANDRG changed in 9% of total cases as a result of recoding. While some cases changed to a higher weighted ANDRG, overall the hospitals would have lost $98,445 after recoding. Significant associations were found between coding errors and poor quality documentation. The results indicate that while the ACS are adhered to, a high degree of coding variation still exists. This is largely due to inadequacies in medical record documentation. Clinicians and coders need to work together to ensure that coding variation is kept to a minimum.