1 Nuance Communications, Inc., USA.
2 Central Michigan University, USA.
Health Inf Manag. 2019 May;48(2):101-108. doi: 10.1177/1833358318781106. Epub 2018 Jun 25.
Multiple studies have questioned the validity of clinical codes in hospital administrative data. We examined variability in reporting a postoperative ileus (POI).
We aimed to analyse sources of coding variations to understand how clinical coding professionals arrive at POI coding decisions and to verify existing knowledge that current clinical coding practices lack standardised applications of regulatory guidelines.
Two medical records (cases 1 and 2) were provided to 15 clinical coders employed by a midsize nonprofit hospital in the northwest region of the United States. After coding these cases, the study participants completed a survey, reported on the application of guidelines, and participated in a focus group led by a health information management regulatory compliance expert.
Only 5 of the 15 clinical coders correctly indicated no POI complication in case 1 where the physician documentation did not establish a link between the POI as a complication of care and the surgery. In contrast, 13 of the 15 study participants correctly coded case 2, which included clear physician documentation and contained the clinical parameters for the coding of the POI as a complication of care. Clinical coder education, credentials, certifications, and experience did not relate to the coding performance. The clinical coders inconsistently prioritised coding rules and valued experience more than education.
The application of International Classification of Diseases, Ninth Revision, Clinical Modification; coding conventions; Centers for Medicare and Medicaid Services coding guidelines; and American Hospital Association coding clinic advice was subject to the clinical coders' interpretation; they perceived them as conflicting guidance. Their reliance on subjective experience in dealing with this conflicting guidance may limit the accuracy of reporting outcomes of clinical performance.
多项研究对医院管理数据中临床代码的有效性提出了质疑。我们检查了术后肠梗阻（POI）报告的变异性。
我们旨在分析编码变化的来源，以了解临床编码专业人员如何做出 POI 编码决策，并验证现有的知识，即当前的临床编码实践缺乏对监管指南的标准化应用。
向美国西北部一家中等规模非营利性医院的 15 名临床编码员提供了两份病历（病例 1 和 2）。在对这些病例进行编码后，研究参与者完成了一项调查，报告了指南的应用情况，并参加了由一名健康信息管理法规遵从性专家领导的焦点小组。
只有 5 名临床编码员在病例 1 中正确表示没有 POI 并发症，而医生的记录没有将 POI 作为护理并发症与手术联系起来。相比之下，15 名研究参与者中有 13 人正确编码了病例 2，其中包括明确的医生记录，并包含了将 POI 作为护理并发症进行编码的临床参数。临床编码员的教育、资质、认证和经验与编码表现无关。临床编码员对编码规则的重视程度不一致，他们更重视经验而不是教育。
国际疾病分类，第九修订版，临床修正版；编码惯例；医疗保险和医疗补助服务中心的编码指南；以及美国医院协会的编码诊所建议都受到临床编码员的解释的影响；他们认为这些指导意见相互矛盾。他们在处理这种相互矛盾的指导意见时依赖主观经验，这可能限制了报告临床绩效结果的准确性。
