Document 3:5 (2016-2017) / Published 23.03.2017 Investigation of medical coding practice within the health enterprises

Findings

The quality of medical coding is poor

The health enterprises are responsible for submitting to the Norwegian Patient Register information which is correct and relevant to the treatment that the patient has received during their period of admission. Amongst the pneumonia patients, an incorrect principal diagnosis was reported for 41 percent of admissions. One in three errors in these admissions was due to the medical record describing a clinical condition other than pneumonia as the principal condition. The other errors were due to the code giving an inaccurate picture of the cause of the patient's pneumonia. This reduces the quality of the patient statistics.

The health enterprises are not monitoring code quality sufficiently well to ensure good patient statistics

Although the health enterprises have implemented numerous initiatives to improve code quality in recent years, management of the work relating to codes is still inadequate in many enterprises. An important cause behind this is a lack of knowledge of coding amongst the doctors. It is important that the doctors undergo training and receive feedback on their own coding. Clear management which supports the code work is also vital.

Poor code quality has adverse consequences for the management and financing of the specialist health service

Stakeholders at all levels use data from the medical codes for statistics, health monitoring, research and planning. Poor code quality will cause decisions that are taken on the basis of the codes to be based on erroneous premises.

Recommendations

The Office of the Auditor General recommends that:

• the health enterprises promote better medical coding by providing their employees with the requisite updated knowledge concerning coding and requirements for medical record documentation, and by giving clear signals concerning the importance of correct coding to ensure accurate patient statistics
• the regional health enterprises play a greater role as a driving force to ensure good and consistent medical coding
• the Directorate of eHealth facilitates good coding through the provision of guidance and the development of support tools
• the Ministry of Health and Care Services follows up to verify that the Directorate of eHealth and the regional health enterprises ensure that the health enterprises' coding is of good and uniform quality, so that assessments and decisions within the specialist health service are made on the right basis

Background and objectives of the investigation

Medical coding entails converting textual descriptions of diagnoses and procedures in medical records into codes. An important purpose of medical coding is to obtain an overview of diseases amongst the population. The codes also provide a basis for planning, administration, financing, management and quality assurance of the specialist health service. The investigation was based on two patient groups which are examined and treated at most hospitals: pneumonia patients and hip replacement patients.

The objective of the investigation was to examine how the health enterprises, the regional health enterprises, the Directorate of Health and the Directorate of eHealth (NDE) fulfil their responsibility to promote good code quality.