Physician-clinical coder collaboration effectively improves coding accuracy: A single-centre prospective study in...

Area of Science:

• Health Informatics
• Medical Coding
• Healthcare Administration

Background:

• Clinical coding is vital for healthcare operations, including reimbursement, resource allocation, administration, and medical research.
• Accurate clinical coding ensures proper financial reimbursement and supports effective healthcare management.
• The quality of clinical documentation, particularly homepage completion, significantly influences coding accuracy.

Purpose of the Study:

• To evaluate the accuracy of clinical coding and identify factors influencing it.
• To assess the impact and benefits of collaboration between physicians and clinical coders.
• To investigate the relationship between documentation quality, coder performance, and overall coding accuracy.

Main Methods:

• A quality audit involving 24 physicians and one senior clinical coder.
• Utilized International Classification of Diseases (ICD) guidelines and specific homepage standards for accuracy assessment.
• Analyzed 323,320 medical records, comparing coding accuracy and correction rates before and after physician-clinical coder collaboration.

Main Results:

• Average coding accuracy was 83.4%, with poor-quality homepages contributing to 89.9% of errors.
• Physician-clinical coder collaboration increased coding accuracy from 78.9% to 87.1% and correction rates from 52.0% to 73.0%.
• Factors influencing accuracy included medical record complexity, homepage quality, collaboration duration, coder's major, experience, work engagement, and day of the week.

Conclusions:

• Physician-clinical coder collaboration is an effective strategy for enhancing clinical coding accuracy.
• While collaboration improves coding accuracy, it does not inherently improve the quality of medical record homepages.
• Homepage quality and psychological factors remain significant determinants of clinical coding accuracy.