Aberrant clinical coding: an underappreciated entity for NHS Trusts, clinicians and coders

Abstract

Medical records are important not just as a conveyor of clinical information but also as a key method of monitoring and reporting hospital service activity. Each activity is allocated a specific code, which is used for reimbursement purposes. The accuracy of the information in the medical notes is therefore crucial for allocating the correct codes. Under the payment by results (PbR) system in England, hospital Trusts therefore have a financial incentive to ensure efficiency and quality in medical record keeping. Inaccuracies in coding in the UK are well known and have been well-reported by the Audit Commission. The average Healthcare Resource Group (HRG) error report rate was 8.1%, with considerable variation (range 1–40%). The level of coding errors is cause for concern, given the current economic climate. Diagnosis Related Groups (DRGs) systems have been utilised in North America as a means of classifying hospital ‘products’ and services for use with prospective payment systems and reimbursement by Medicare for the last three decades. Errors in this system have been reported at a rate of over 20%. Moreover, ‘DRG creep’ (changes in hospital record-keeping practices to increase case-mix indexes and reimbursement) occurred in over 60% of the errors leading to over-reimbursement of services covered by Medicare.