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Clinical Coding Audits: An Annotated Bibliography

The accuracy of clinical morbidity coding is vitally important for all groups who use the resulting databases for the purposes of health services research, allocation of funding, evaluation of health services and clinical interventions, and health services planning (Cornes 1999; Roberts et al 2002). A variety of quality improvement techniques are used to assess the accuracy of clinical morbidity coding, and to introduce changes such as coder and clinician education, clinical documentation, software edits, and coding standards, all of which aim to address issues identified in the accuracy assessment process. Audits are performed by various organisations including health authorities and other funders (such as insurance companies, the Department of Veterans’ Affairs, Transport Accident Commissions), research groups, individual health services, and other agencies with a vested interest in coded data quality (such as the National Centre for Classification in Health, and the Australian Institute of Health and Welfare). These audits include statistical analysis of morbidity databases, using products such as Performance Indicators for Coding Quality, to identify compliance with coding standards, and medical record recoding audits which also assess code selection and sequencing based on medical record content (Reid et al 1999; O’Connell & Perry 2003). The aim of this project was to identify literature relevant to recoding audits of clinical morbidity data which had been published since the annotated bibliography on data quality was prepared by Chicco in 1997.