Problems and Barriers during the Process of Clinical Coding: a Focus Group Study of Coders' Perceptions

Area of Science:

• Health Informatics
• Medical Coding Quality Assurance

Background:

• Coded data, including administrative and clinical information, are fundamental for hospital reimbursement systems globally, often utilizing Diagnosis Related Groups (DRG).
• Ensuring the quality of coded data is essential for improving data usability, enhancing patient outcomes, and optimizing healthcare financing.

Purpose of the Study:

• To explore the challenges and barriers impacting the quality of the clinical coding process.
• To identify potential solutions for improving clinical coding accuracy and efficiency.

Main Methods:

• Qualitative study involving ten medical coders from four public hospitals in Portugal.
• Focus group sessions were conducted, audio-recorded, transcribed, and analyzed thematically.
• Problem identification was informed by existing literature and expert knowledge.

Main Results:

• Identified problems include variability in coding documents, illegible handwriting, transcription errors, diagnostic coding difficulties, and delays.
• Unavailability of adequate resources and tools for coders was also a significant barrier.
• Coders highlighted issues stemming from the manual transcription process.

Conclusions:

• Standardizing coding documents, adopting electronic coding systems, and developing supportive tools are key solutions.
• Implementing regular audits and gaining management recognition for the importance of coding are crucial for data quality improvement.