Clinical coding: how accurately is it done?

Clinical coding is a process of accurate translation of written medical terms into codes. The Payment by Results initiative has focused attention on the quality of clinical coded data as all income for in patient services is derived from coded clinical data. The aim of this study was to evaluate the quality of clinical coded data by making comparisons between the information held on the dialect encoder system and the information recorded in the clinical case notes.

The 50 episodes for this study were randomly selected from a list of all episodes ending August 2005 within the ENT specialty in a teaching hospital.

There were only 17 (34 per cent) episodes with a structured summary within the case notes. Of the 50 recorded primary diagnoses 42 (84 per cent) were correctly coded. Of the 43 recorded primary procedures, 37 (86 per cent) were correctly coded.

This study promotes a better awareness of the impact of poor coding and gives recommendations that will be helpful to those involved in coding processes.