Factors Affecting the Medical Coding Errors of COVID-19 Hospital Records: A Cross-Sectional Study in East Iran.

Abstract

Background: During the COVID-19 pandemic, disease coding significantly influenced national and international strategies for prevention, treatment, and control. This study aimed to assess the factors influencing COVID-19 records' coding errors in teaching hospitals in South Khorasan province.

Materials and methods: In 2022, researchers conducted a cross-sectional study in South Khorasan Province, Iran. Data was gathered using a self-developed questionnaire distributed among medical coders in all hospitals. Descriptive statistics were employed in the data analysis using SPSS version 19.

Results: The study's results showed that non-observance of diagnostic principles by physicians (66 out of 92), a lack of specialized medical coding specialists (52 out of 92), and the use of ambiguous and non-standard abbreviations (51 out of 92) were the most significant factors affecting COVID-19 coding errors. Among the three main factors affecting COVID-19 records' coding errors, factors related to the medical coder (47.66 out of 92), factors related to healthcare providers (29.8 out of 92), and organizational and environmental factors (21.4 out of 92) were the most significant.

Conclusion: This study revealed that multiple factors contribute to coding errors in COVID-19 records, with the most critical being physicians' non-adherence to diagnostic principles, the shortage of medical coding specialists, the use of unclear and non-standard abbreviations, and the absence of COVID-19 coding continuing education. Therefore, we recommend conducting workshops on diagnosis and coding for medical coders, particularly emphasizing the precise coding of COVID-19 records.