Healthcare Coding Discussion: HIMs, CCs, and Documentation Challenges

This discussion forum post examines critical issues in healthcare coding, focusing on the responsibilities of Health Information Managers (HIMs) and Clinical Coders (CCs) in translating inpatient episodes into diagnosis and procedure codes, compliant with Australian Coding Standards. The author agrees that the use of 'unspecified' codes often stems from inadequate clinician documentation, emphasizing the need for accurate and comprehensive records. The post also addresses how the inexperience of HIMs/CCs and the need to improve the current classification system used for injuries and nosocomial complications compromise the quality of coded data. The author references studies and provides insights into the implications for stakeholders, including the need for improved training and documentation practices to enhance coding accuracy and patient care. The assignment also looks at the language used for coding and how the entry system can be improved to minimize the chances of missing information. It provides a comprehensive analysis of the challenges and potential solutions in healthcare coding practices.

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1. The use of ‘unspecified’ codes by HIMs and CCs, when they are coding injuries and
nosocomial complications, is often a result of inadequate documentation by clinicians.
I agree with the statement that the use of unspecified codes by the HIMs is due to poor
documentation by the clinicians. It is because most of the researchers that have been published
do not show the reluctance of the patient in giving out information. As such, the lack of enough
data is attributed to the clinicians who may insufficiently record the patient information or
question him. The clinicians need to update the documentation of nosocomial complications for
efficient coding frequently. Documentation plays a significant role in coding, as the periods are
vital while coding. It also inhibits the wrong reflection of the illness. Sometimes the herbal
medicines, which sometimes have severe effects on the patients, are not recorded. It leads to
grave consequences to the patient as well as the HIMs since the patient may deteriorate in health
when given the wrong medication. It also affects the HIMs diagnoses as they follow the
misleading documentation making them follow the wrong procedures. The patient also does not
get the health care resources needed for him because of poor coding emanating from false
documentation
2. The quality of coded data is compromised by the HIMs / CCs’ inexperience in coding
or lack of clinical knowledge.
I highly rank this statement as the statistics that various researchers have made show that
about 50%of cases in Australia have been correctly documented. (Cunningham, et al. 2013).
However, though the cases are accurately recorded there is an inadequacy in coding which brings
adverse effects. To rectify the situation one should carefully examine the information; it involves

paying attention to the definitions, as each of them is crucial in identifying the complications
such as allergies. The improvement in coding might be made by conducting training. Training
should frequently be conducted about the complications to add to the expertise knowledge as
well as the proper definition of the complications.
3. The classification used for assigning diagnosis and procedure codes for injuries and
nosocomial complications in Australia needs improvement.
I agree with the statement that the classification that is currently used in assigning the
diagnosis, as well as procedure codes for injuries, needs to be improved.one of the aspects that
need to be examined is the language that is used in coding. The language that is currently used is
so complex hence; there is a need to improve on it. The classification is also so sophisticated
hence; there is a need to make it bit simple. Improvement also needs to be done on the entry
system since with the current regime at times some information misses out. However the current
classification is better than the paper work that led to legibility problems, it just needs few
improvement. (Paul& Robinson, 2012
References
Cunningham, J., Williamson, D., Robinson, K.M. and Paul, L. 2013. A comparison of
state and national Australian data on external cause of injury due to falls. Health Information
Management Journal 42(3): 4-11.
Paul, L. and Robinson, K. 2012. Capture and documentation of coded data on Adverse
Drug Reactions: an overview. Health Information Management Journal 41(3): 27-36.