In Australia, coding of procedures, diagnoses and admissions is a key factor in the allocation of funds to the various health services, and departments within those services. Currently within the Gold Coast Hospital and Health Service, the coding of operations happens firstly in theatres towards the end of an operation by nursing staff who usually discuss with the surgeons what the most appropriate operation title may be. This title is entered into a program called ORMIS and a code is generated. ORMIS staff then analyse these codes and generate surgical summaries from data for the purposes of audit and further research, as well as for hospital administration and executive teams.
We performed a review of all ORMIS coding data over a 1-month period. We found an alarming number of incorrect codes. 132 procedures were performed over that month, with an associated 254 codes generated. When reviewed by the surgical team, we found that 29 (11.0%) of these codes were incorrect, 49 codes were missing, 10 codes (3.9%) were unnecessary additional codes, and 3 codes (1.2%) were inadequate to describe the procedure but not incorrect.
We have fed these results back to our ORMIS department and are conducting meetings to determine the value of continuing this method of coding. The coding staff that submit reports to the health department are separate from the ORMIS department, and perform their own reviews of operation notes, progress notes and discharge summaries among other documents to formulate the final codes for surgical inpatients. An accurate and detailed operation note is adequate information for the coding staff to accurately generate procedure codes.