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. 2018 Jan 25;18(1):38.
doi: 10.1186/s12913-018-2843-1.

Potential loss of revenue due to errors in clinical coding during the implementation of the Malaysia diagnosis related group (MY-DRG®) Casemix system in a teaching hospital in Malaysia

S A Zafirah  1   2 , Amrizal Muhammad Nur  3 , Sharifa Ezat Wan Puteh  3 , Syed Mohamed Aljunid  3   4
Affiliations

Potential loss of revenue due to errors in clinical coding during the implementation of the Malaysia diagnosis related group (MY-DRG®) Casemix system in a teaching hospital in Malaysia

S A Zafirah et al. BMC Health Serv Res. .

Abstract

Background: The accuracy of clinical coding is crucial in the assignment of Diagnosis Related Groups (DRGs) codes, especially if the hospital is using Casemix System as a tool for resource allocations and efficiency monitoring. The aim of this study was to estimate the potential loss of income due to an error in clinical coding during the implementation of the Malaysia Diagnosis Related Group (MY-DRG®) Casemix System in a teaching hospital in Malaysia.

Methods: Four hundred and sixty-four (464) coded medical records were selected, re-examined and re-coded by an independent senior coder (ISC). This ISC re-examined and re-coded the error code that was originally entered by the hospital coders. The pre- and post-coding results were compared, and if there was any disagreement, the codes by the ISC were considered the accurate codes. The cases were then re-grouped using a MY-DRG® grouper to assess and compare the changes in the DRG assignment and the hospital tariff assignment. The outcomes were then verified by a casemix expert.

Results: Coding errors were found in 89.4% (415/424) of the selected patient medical records. Coding errors in secondary diagnoses were the highest, at 81.3% (377/464), followed by secondary procedures at 58.2% (270/464), principal procedures of 50.9% (236/464) and primary diagnoses at 49.8% (231/464), respectively. The coding errors resulted in the assignment of different MY-DRG® codes in 74.0% (307/415) of the cases. From this result, 52.1% (160/307) of the cases had a lower assigned hospital tariff. In total, the potential loss of income due to changes in the assignment of the MY-DRG® code was RM654,303.91.

Conclusions: The quality of coding is a crucial aspect in implementing casemix systems. Intensive re-training and the close monitoring of coder performance in the hospital should be performed to prevent the potential loss of hospital income.

Keywords: Casemix system; Clinical coding; Coding error; DRG; Diagnosis coding; My-DRG®; Procedure coding.

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Conflict of interest statement

Ethics approval and consent to participate

Ethical approval to undertake this study was applied before starting the data collection in July 2014. Ethical approval was officially obtained from the Ethics Committee at the Universiti Kebangsaan Malaysia on 19 May 2014 (Reference Number: UKM.1.5.3.5/224/UNU-003-2014).

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow of Casemix System. Casemix is a patient classification system where there were two main components namely Clinical Coding and Cost Analysis. The coding process is conducted according to the International Classification Disease 10th Revision (ICD 10) for diagnosis coding and International Classification of Disease Ninth Clinical Modification (ICD-9 CM) for procedure coding. On the other hand, costing methods that are usually employed in Casemix System are Top Down Costing and Activity Based Costing. In Casemix system, the information from the clinical coding process is used to generate the MY-DRG® Code, and these codes will be assigned to a hospital tariff according to the cost weight calculated at the cost analysis part
Fig. 2
Fig. 2
Structure of MY-DRG® Code. “A” indicates the CMG Group. “4” indicates the discipline. “23” indicates the DRG Code. “I” indicates the severity level of the patient
See this image and copyright information in PMC

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