Navigating the Maze of Clinical Coding in Oral Surgery: A Call for Accuracy and Improvement

Imagine you are at your dentist’s office for an oral surgery. You’re probably thinking about the procedure, its success, and perhaps your recovery time. But have you ever thought about the administrative side of things, like clinical coding? You might wonder, ‘What’s that?’ or ‘Why does it matter?’

Clinical coding is a crucial yet often overlooked aspect of healthcare that involves translating the details of your health condition and treatment into standardized codes. These codes not only record patient data but also affect hospital revenues. However, when codes are misinterpreted or overlooked, it can lead to inaccuracies and financial discrepancies.

A study by Naran, Hudovsky, Antscherl, Howells, and Nouraei took a deep dive into this topic, specifically focusing on oral surgery. They aimed to assess the accuracy of clinical coding within this field and identify ways to enhance it.

They audited a sample of 646 patients who underwent oral surgery procedures between 2011 and 2012. These patients were all day case patients, meaning they were admitted and discharged on the same day. The researchers compared the codes given with the patients’ case notes and rectified any discrepancies they found.

And what they found was quite shocking!

In 19% of the cases, primary diagnoses changed due to inaccurate coding. Primary procedure codes needed amending in 35% of cases, while 48% of morbidities and complications had been missed. Not just that, but 41% of secondary procedures had either been missed or were incorrectly coded. In fact, at least one change in coding was needed for 77% of patients, affecting the Health Resource Groupings (HRGs) in 54% of cases. This resulted in a financial impact of £114 in lost revenue per patient.

One might wonder, why are there so many coding errors in oral surgery?

The reasons include the large number of day cases, a lack of awareness among clinicians about coding issues, and clinical coders not always being familiar with the many highly specialised abbreviations used in the field.

So, how can we fix this?

The researchers proposed the use of a well-designed proforma, a type of form or template, to improve the accuracy of coding. To maintain these standards, they recommended the implementation of an ongoing data quality assurance program.

This study serves as a wake-up call for all involved in oral surgery. Accurate clinical coding isn’t just about getting the admin right; it’s about ensuring the quality of patient care and the financial health of the hospital.

So, the next time you’re at the dentist, remember – even as you sit in that chair, there’s a world of data and codes working in the background to make your care as smooth and effective as possible. Here’s to hoping that with studies like these, that background work will become even more accurate and efficient!


S. Naran, A. Hudovsky, J. Antscherl, S. Howells, S.A.R. Nouraei, Audit of accuracy of clinical coding in oral surgery, British Journal of Oral and Maxillofacial Surgery, Volume 52, Issue 8, 2014, Pages 735-739, ISSN 0266-4356,

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