Abstract
Background Coding in medical procedures is crucial for patients, and errors made by hospital administration during the coding process can have an impact on both the financial results and the course of therapy. The present study aims to assess the accuracy of diagnostic and procedural codes as recorded by the hospital’s coders and to also evaluate their impact on the hospital’s revenue. Methods In a local hospital in Najran, Saudi Arabia, a cross-sectional observational analysis was conducted on patients with a clinical coder. The percentage of precision and error following the re-coding of cases was calculated using a statistical analysis. Results Primary diagnosis was incorrectly coded in 57 (26 per cent) records, and secondary diagnosis was incorrectly coded in 21 (9.9 per cent) records. Inaccurate medical labelling has been seen in emergency rooms, operating rooms, and gynaecology facilities. Discussion The percentage of records with the most incorrect coding was found to be 16 (7.5 per cent) in the emergency room, 10 (4.7 per cent) in the surgical clinic, and 5 (2.3 per cent) in the gynaecology/OBS clinic. Six (2.8 per cent) records in the private clinic had inaccurate secondary diagnoses, followed by four (1.9 per cent) and two (1 per cent) records in nephrology. Conclusion The percentage of inaccurate clinical codes in primary diagnoses reached (26.8 per cent) and the percentage of incorrect clinical codes in secondary diagnoses reached (9.9 per cent).