Supervision of Coding Pratice
Summary of Report of the Norwegian Board of Health Supervision 10/2004
On 17 February 2003, the Norwegian Board of Health received information that indicated that there was a possibility that diagnoses for patients treated at the hospital Sørlandet sykehus HF in Arendal had been coded incorrectly.
In September 2003, the Norwegian Board of Health carried out special supervision of the ear, nose and throat (ENT) department and the neurological department in Sørlandet sykehus HF Arendal. The neurological department was chosen as a reference department. It was decided that similar supervision of several other hospitals should be carried out, in order to obtain a broader picture of coding practice. The Norwegian Board of Health thus carried out supervision of the ENT departments and the neurological departments in the following hospitals: Helse Nordmøre og Romsdal HF Molde sjukehus and Sykehuset Østfold HF Fredrikstad.
Through supervision, the Norwegian Board of Health identified the following:
- Several patients in the ENT department Sørlandet sykehus HF Arendal had been given the diagnosis sleep apnoea, although the main symptom of this disorder was neither recorded in the referral letter nor in the patient record. In addition, 20 % of the records that were checked in the same department were inadequate according to the regulations for patient records.
- All the health trusts coded incorrectly in relation to the current coding regulations for hospital stay. The neurological departments had a higher frequency of incorrect coding than the ENT departments, in some cases as high as 70 %.
- There were great inconsistencies between the diagnosis and procedure codes that were recorded in the patient records, and the codes that were reported to the Norwegian Patient Register. This was the case for the ENT departments and the neurological departments in Sørlandet sykehus HF Arendal and Helse Nordmøre og Romsdal HF Molde sjukehus.
In the view of the Norwegian Board of Health, this evaluation indicates inadequate quality control of the basic data that is used for calculating hospital revenue.