The importance of the coding accuracy using the diagnosis - related groups coding system for health care institution

Aim of the study: To assess the importance of the coding accuracy using the Diagnosis - Related Groups coding system for health care institution. Objectives: 1. To identify the most common documentation errors using Diagnosis - Related Groups coding; 2. To identify the most common errors of Diagnosis - Related Groups coding which can reflect on case pricing; 3. To perform the cost analysis of Diagnosis – Related Groups coding errors that affect case pricing. Methods. A total of 222 surgical inpatient discharges of two units of the „N“ clinics within a one-month period (October 1 – 31, 2014) has been reviewed for the accuracy and completeness of documentation and coding of primary and secondary diagnoses and procedures. Discrepancies between the submitted codes and the information in medical records were compared. Coding errors were grouped and statistically analysed by categories. Statistical analysis was performed using the SPSS statistical package (version 17.0) and Microsoft Office Excel 2010. Results. The most common documentation errors are writing of incorrect rehabilitation codes (53.2 percent), missing external cause codes (47.6 percent), the differences in the primary diagnose coding when patients were moving between units (21.3 percent) and not marking that the case belongs to the day-time surgery. 75 percent were incorrectly coded secondary diagnoses, 13.5 percent incorrect primary diagnoses and 11.5 percent procedures (not coded general anaesthesia, MRI, CT). The analysis revealed documentation inaccuracies in 61.3 percent of cases, and cost-affecting inaccuracies in 20.7 percent of cases