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Related Experiment Video

Updated: May 10, 2026

Measuring 3D In-vivo Shoulder Kinematics using Biplanar Videoradiography
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Measuring 3D In-vivo Shoulder Kinematics using Biplanar Videoradiography

Published on: March 12, 2021

Cracking the code: the accuracy of coding shoulder procedures and the repercussions.

N D Clement1, I R Murray, Y X Nie

  • 1Department of Trauma and Orthopaedic Surgery, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK. nickclement@doctors.org.uk

Scottish Medical Journal
|June 4, 2013
PubMed
Summary

Coding errors in patient diagnoses and procedures are common, impacting resources. A new coding proforma significantly improved accuracy and increased revenue by addressing unclear notes and ambiguous codes.

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Area of Science:

  • Medical Coding Accuracy
  • Healthcare Resource Management
  • Surgical Procedure Classification

Background:

  • High rates of coding errors (up to 40%) in patient diagnoses and surgical procedures negatively affect resource distribution and financial reimbursement.
  • Existing coding practices struggle with accuracy, particularly for shoulder-related diagnoses and procedures.

Purpose of the Study:

  • To investigate the root causes of coding errors for shoulder diagnoses and surgical procedures.
  • To develop and evaluate a novel solution to mitigate these coding inaccuracies.

Main Methods:

  • Retrospective review of 100 surgical patient records to identify and analyze coding errors.
  • Development and prospective evaluation of a specialized coding proforma for 100 patients.
  • Assessment of the financial impact of coding errors and the proposed solution.
Keywords:
Codingcostpayment by resultsshouldertariff

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Main Results:

  • Initial retrospective analysis showed low accuracy: 54% correct primary diagnosis and only 7% correct procedure codes.
  • Identified causes included indistinct clinical notes and unclear procedure code descriptions.
  • The proforma dramatically improved accuracy: increased odds of correct diagnosis (OR 18.2) and procedure code (OR 310.0).
  • Implementation led to a £28,562 revenue increase for 100 patients.

Conclusions:

  • Coding inaccuracies stem from misinterpreting clinical notes and ambiguous procedure codes.
  • A simplified coding proforma, allowing surgeons to directly assign diagnoses and procedures, significantly enhances accuracy.
  • This approach improves coding quality and has substantial positive financial implications.