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[Diagnosis versus code]
1Statens helsetilsyn, Postboks 8128 Dep, 0032 Oslo. ghh@helsetilsynet.no
Insights
Coding accuracy in Norwegian hospitals is a concern. A review found frequent inaccuracies in diagnoses and coding, impacting patient record integrity and reporting to the Norwegian Patient Register (NPR).
Area of Science:
- Healthcare quality assurance
- Medical coding practices
- Health information management
Background:
- Norwegian Board of Health supervision of ENT and neurological departments (2003-2004).
- Investigated coding practices and diagnostic accuracy in regional hospitals.
Purpose of the Study:
- To assess the accuracy of diagnoses and medical codes in patient records.
- To evaluate consistency between patient records and reported codes to the Norwegian Patient Register (NPR).
Main Methods:
- Review of 100 patient records per department across three hospitals.
- Comparison of diagnoses and codes within patient records.
- Validation of codes against the Norwegian Patient Register (NPR).
Main Results:
- Systematic incorrect diagnoses in one ENT department.
- Widespread incorrect coding, particularly in neurological departments.
- Significant discrepancies between patient record codes and NPR-reported codes.
Conclusions:
- Diagnoses were rarely wrong but often imprecise due to ICD-10 limitations.
- Hospital stay coding rules were often disregarded.
- Alterations to NPR codes occurred without medical justification or record updates.
Background:
As a result of information about coding practice in a regional hospital, the Norwegian Board of Health carried out a special supervision of ear, nose and throat (ENT) departments and neurological departments during the autumn of 2003 and the spring of 2004. The aim was to investigate whether there was accordance between information in the patient records and the chosen diagnoses and codes.
Material And Method:
Three hospitals were examined. Information in 100 selected patient records from each department was compared with diagnoses and codes. The codes reported to the Norwegian Patient Register (NPR) from two hospitals were compared with codes in the patient records.
Results:
Incorrect diagnoses had been systematically recorded in one ENT department. Incorrect codes had been recorded in all the departments, especially the neurological departments. Many inconsistencies between codes in the patient records and those reported to NPR were found.
Interpretation:
Wrong diagnoses were seldom made, but many diagnoses were unprecise because only ICD-10 diagnoses were used. The rules of coding hospital stays were frequently not used. Many of the codes reported to NPR had been altered, without medical basis and without being noted in the patients' records.
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