Coding in surgery: impact of a specialized coding proforma in hepato‐pancreato‐biliary surgery

BackgroundCoding inaccuracies in surgery misrepresent the productivity of hospitals and outcome data of surgeons. The aim of this study was to audit the extent of coding inaccuracies in hepato‐pancreato‐biliary (HPB) surgery and assess the financial impact of introducing a coding proforma.MethodsCoding of patients who underwent elective HPB surgery over a 3‐month period was audited. Codes were based on International Classification of Diseases 10 and Office of Population and Census Surveys‐4 codes. A coding proforma was introduced and assessed. New human resource group codes were re‐assigned and new tariffs calculated. A cost analysis was also performed.ResultsPrior to the introduction of the coding proforma, 42.0% of patients had the incorrect diagnosis and 48.5% had missing co‐morbidities. In addition, 14.5% of primary procedures were incorrect and 37.6% had additional procedures that were not coded for at all. Following the introduction of the coding proforma, there was a 27.5% improvement in the accuracy of primary diagnosis (P < 0.001) and 21% improvement in co‐morbidities (P = 0.002). There was a 7.2% improvement in the accuracy of coding primary procedures (P = not signifi