Common Coding Errors in Obstetric Macrosomia Diagnosis
Objectives This study aims to analyze the coding errors of obstetric macrosomia in a hospital to provide a reference for improving coding quality.Methods A total of 292 medical records of macrosomia infants with ICD-10 codes of O33.5,O36.6,and O66.2 discharged from a certain hospital from January 1,2018 to December 31,2019,were retrieved and rechecked according to the coding rules for obstetric macrosomia.SPSS 24.0 software was used to establish the database,and the supplementary test method of the chi-square test and Fisher's exact probability method were used for parallel descriptive statistical analysis.Results The coding error rate for obstetric macrosomia in a hospital was 15.41％,and there was a statistical difference in the composition ratio before and after the review(P＜0.001).38 cases should be coded as O33.5 for maternal medical treatment for pelvic disproportion caused by extra-large fetuses but were mistakenly coded as O36.6 for maternal medical treatment for fetal overgrowth.7 cases should be coded as O66.2 for maternal medical treatment for fetal pelvic disproportion caused by extra-large fetuses but were mistakenly coded as O36.6 for maternal medical treatment for fetal overgrowth.There was a total of 45 coding errors.The highest error rates before and after the coding review were O36.6 and O33.5.Conclusions Coders do not have enough knowledge of the coding rules for obstetric macrosomia and ignore factors such as the start time of labor,accompanying symptoms,clinical knowledge,and poor sense of responsibility,which directly affects the quality of coding.Strengthening the professional skills training of coders and internal coding quality control should improve the accuracy of coding and provide accurate information support for maternal health management and data monitoring.
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