The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding
In the article titled, “The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding” the authors proved through an audit of medical records, that the biggest financial losses were a direct result of either improper clinical documentation or lack of documentation altogether. The objectives in conducting both an internal and a blind audit at a hospital in Melbourne, Australia were to measure discrepancies in clinical coding, identify financial loss associated with diagnosis related group (DRG) changes, reveal errors associated with improper documentation, and to suggest strategies for improvement. Out of 752 cases, there was a substantial margin of error after the original codes were compared with audited codes. To identify specific underlying factors each case was analyzed. In reference to DRG changes, the study revealed an overpayment of at least 16%, with 56% of the error a result of poor documentation (Cheng, et al., 2009). Only 13% of the mistakes were related to actual coding errors with the remaining contributed to missing or inaccurate diagnoses in the medical chart.
In conclusion, the case study confirmed the importance of regular auditing of medical charts both to reduce financial losses and to improve strategies for controlling preventable errors. By tracking coding and documentation errors on a regular basis, the issue can be addressed in a timely manner and the consequences of these errors can be minimized. In the aftermath of the case study, auditor recommendations for securing reimbursements included, continuing education courses for employees on proper documentation, coding requirements, and DRGs, in combination with frequent meetings with the internal clinical auditor to assess employees’ comprehension regarding...
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