Is coding in theatres a viable option? A review of the current theatre coding process at Royal Prince Alfred Hospital

A study was undertaken to review the process of procedure coding in the four major operating theatres at Royal Prince Alfred Hospital, Sydney. Recommendations were made regarding the viability of theatre coding, using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD9CM), and the steps which must be undertaken to ensure theatre coding is accurate. A retrospective coding audit was conducted to ascertain the quality of coding of procedures by theatre staff, usually nurses, compared to clinical coders from the Medical Record Department. The results showed that the overall error rate for theatre coding staff was 86% compared with the Medical Record Department's clinical coders error rate of 18%. The reasons for the high theatre coding error rate were: lack of formal training in ICD9CM coding; out of date code books; lack of networking with other coders and the National Centre for Classification of Health; coding from the Operating Room - Registered Nurses Report (MR370) rather than the operation sheet and lack of theatre coding audits. It was concluded that theatre coding could replace Medical Record Department procedure coding if the issues highlighted in this study were addressed. It should be noted however that there are a number of 'procedures' which need to be coded and are not performed in the operating theatre. A mechanism for coding these procedures (for example epidural, ventilation, allied health interventions) needs to be addressed. (author abstract)