The Impact of the Clinical Miscoding on Inpatient Reimbursement

Abstract

Background: The purpose of this study was to investigate the rate of coding errors and its effect on the amount of correct reimbursement to patients. Methods: This descriptive and cross-sectional study was performed in 2018. Research resources were records in compensation units in medical documents center of social security organization. A total of 546 records were reviewed of which, 118 records met the research criteria and were selected through census method. Instrument for data collection was a checklist composed of six parts. Data were collected by compensation unit coders. Results: In total, 118 records met the inclusion criteria. The highest rate of documentation error was related to unconfirmed errors with 106 items and a coefficient of 3845.44. The cost issued to patients based on tariff codes with a coefficient of 9696.4 was estimated as 3684632000 Rials, which only 2416154000 Rials was reimbursed to the patients with the coefficient of 6358.3. Conclusion: Since coding of diagnostic measures had a high percentage of errors, and the recording of services was not accepted, some proper policies must be adopted to reduce procedure miscoding.

Keywords

• coding
• miscoding
• tariffs
• patient reimbursement