The biggest clinical coding challenges faced by health information managers

Clinical coding now plays a critical role in health information management

As the field continues to expand, so too is its importance in supporting the effective management of hospitals – from ensuring quality patient care to funding models and infrastructure development.

However, there are still barriers that exist today hindering clinical coders in achieving quality clinical coding outcomes. In this article, we detail some of the most pressing clinical coding challenges affecting the accuracy and timeliness of reporting. We also look at the key opportunities for improvement to ensure the quality and integrity of health data while supporting the clinical coding and health information management workforce.

Documentation of Clinical Events

The information from healthcare providers is an influential resource to data quality.

However, due to incomplete clinical documentation, the accuracy of clinical coding is affected (e.g. missing discharge or surgical notes or incorrect documentation of procedures and specificity of diagnoses).

A research study from the Health Information Management Journal shows that most clinical coding managers identify poor chart documentation as one of the causes of poor quality clinical coding. When chart documentation lacks clarity and legibility, under-coding can happen, causing hospitals to lose revenue. It can also create compliance issues and inadequate quality-of-care reviews.

Variability in Interpretation

The integrity of the coded data is also often compromised due to variations in documentation and coding standards interpretations.

This happens when coders have to identify the more correct coding scenario while working with unidentified diagnoses, and documentations that lack legibility, are unspecified or incomplete.

Inconsistent terminology and the use of non-standardised acronyms also cause the health information to be mistranslated. This usually occurs when there are variations in diagnosis description depending on the hospital, specialty or even the healthcare professional.

Chart Organisation and Assembly

Disorganised charts and slow turnaround time have also been reported to cause a delay in the coding process.

Charts that have not been properly organised and assembled often result in frustration and efficiencies. While delays in chart completions by physicians introduce further issues to clinical coders and health information managers (HIMs), who are already subject to the pressure of meeting their coding quota.


The presence of quota is another factor that creates an adverse effect on the productivity of clinical coders.

This type of pressure can often cause errors as clinical coders tend to focus on quantity over quality to meet their targets.

Clinical coders are also expected to stay on top of the ever-changing standards and coding advice. Without support for continuing education, it can be challenging for clinical coders and their managers to keep up with revised coding guidelines – of which they usually need to learn within short time frames.

The lack of engagement between the clinical staff and coding professionals also impacts the quality of clinical coding. When communication with physicians is limited, the opportunity to get feedback and clarification of conditions is also reduced.

Key Opportunities

While the above barriers continue to exist today, there are opportunities for hospitals to significantly improve their documentation and coding accuracy. We highlight a few examples below that can help facilitate high-quality coding practices.

Continuous Training

Education is essential to support the growth and development of clinical coders.

By providing interactive training and continuous education, you can ensure your team receives the most up-to-date coding information. This translates to:

  • Improved employee retention;
  • Enhanced coding quality and accuracy;
  • Reduced denials; and
  • Consistent compliance with coding and billing practices.

You can support your clinical coders’ continuous education and training by providing:


  • The latest resources on clinical coding standards and classifications;
  • In-person training by national health information management organisations; and
  • Webinars.

Getting the Correct Tools

With the increasing amount of healthcare data created and needing to be managed, you need to leverage new technologies that will support your clinical coders and HIMs in their roles.

Below are some of the questions you need to ask when identifying the correct tools to help empower your clinical coding team.


  • Does it allow my team to ensure coding standards are being applied at all times?Auditing tools like Code Focus provides Auditors with the ability to create their own audit rules to target specific coding errors and achieve high-quality data.
  • Does it provide a real-time feedback loop? This capability will enable your coders to further their education and apply their learning to reduce future errors. 

  • Does it help streamline workflows? The best tools should give your Health Information Services team the ability to analyse, automate and streamline clinical coding allocation. 

By having the right tools – from computer-assisted coding systems to auditing tools – you’ll be able to ensure the quality, reliability, storage and accessibility of your coded data.

What’s Next?

Improve the accuracy and timeliness of your reporting.

Get real-time access to your clinical coding and auditing data. Book a demo today to learn more about how Code Focus works. 


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