Coding Geriatric syndromes: How good are we? | JoVE Visualize

Area of Science:

Geriatric Medicine
Health Informatics
Medical Record Analysis

Background:

Accurate hospital coding is crucial for resource allocation and performance measurement.
Limited data exists on the coding quality for hospital admissions of frail older adults, who often present with complex health needs.
Frail older patients frequently have multiple diagnoses, co-morbidities, and functional impairments, complicating accurate coding.

Purpose of the Study:

To evaluate the quality of hospital coding for geriatric syndromes and medical conditions in frail older patients.
To compare the capture rates of geriatric syndromes versus medical conditions in discharge summaries and hospital coding.
To identify potential improvements in the documentation and coding process for this vulnerable population.

Main Methods:

A case note review (CNR) was conducted to identify the presence or absence of four geriatric syndromes and eight medical conditions.
Discharge summaries (DS) and hospital coding (HC) data were reviewed and compared against the CNR findings.
Statistical analysis was used to compare the capture rates of geriatric syndromes and medical conditions by hospital coding.

Main Results:

Of patients with at least one geriatric syndrome noted in the discharge summary, only 40.0% were captured by hospital coding.
In contrast, 91.2% of patients with at least one medical condition noted in the discharge summary were captured by hospital coding (p<0.0001).
This demonstrates a significantly poorer capture rate for geriatric syndromes compared to medical conditions.

Conclusions:

There is a notable deficiency in capturing information on geriatric syndromes in discharge summaries and subsequent hospital coding for frail older adults.
The findings suggest that current documentation and coding practices inadequately represent the complexity of geriatric care.
A problem list bookmark approach is proposed as a potential strategy to enhance the capture of geriatric syndromes and improve overall coding accuracy.