Coding errors of cataract surgeries: analysis and discussions / 中华医院管理杂志

ABSTRACT

Objective To study the problems encountered in the coding of cataract surgeries. Methods Medical record statistical system was used to retrieve 213 such patients discharged from a hospital between January and June 2016. ICD-9-CM-3 coding principle was called into play to analyze the form completion and coding of major surgeries, along with errors found in them. Results Study of the 213 medical records identified 12 errors of surgery form completion from the surgeons′medical record homepages, accounting for 5. 6% of all. With reference to ICD-9-CM-3, 188 errors were found from the surgical coding made by encoders, accounting for 88. 3% of all. 10 copies were missing with surgery coding, accounting for 4. 7%. 13 coding errors were found in major surgical choices, accounting for 6. 1%. Conclusions Failure of the encoders in their command of coding rules for cataract surgery tops the rest as the main reason for the error of surgical coding. Encoders should make effective use of the ICD-9-CM-3 manual, and master both clinical knowledge, professional skill and coding ability.