Accepted for/Published in: Interactive Journal of Medical Research
Date Submitted: Feb 18, 2026
Date Accepted: Jul 14, 2026
Factors Affecting the Accuracy of Clinical Coding in the Casemix System: A Cross-Sectional Study in a Malaysian Teaching Hospital
ABSTRACT
Background:
Accurate clinical coding is critical in the casemix system to ensure proper resource allocation, healthcare policy planning, and data reliability. Inaccurate coding can result in significant financial losses to the hospital. To date, the implications of inaccurate coding in casemix implementations in Malaysia are rarely explored.
Objective:
This study aimed to evaluate the accuracy of clinical coding and identify factors associated with accurate coding practices in a major teaching hospital in Malaysia.
Methods:
A cross-sectional study was conducted using 445 inpatient discharge records from Hospital Canselor Tuanku Mukhriz (HCTM) from January to December 2023. Stratified random sampling was applied across four departments. Coding accuracy was determined by comparing EMR entries to a gold standard set by trained coders and specialists. Descriptive and bivariate analyses were performed accordingly.
Results:
This study found that the overall clinical coding accuracy was 76.4%. Documentation completeness (p < 0.001) and coding turnaround time (p = 0.037) were significantly associated with coding accuracy. Other variables, such as patients’ gender, age, department, and coder experience, were not significantly associated. Clinical coding accuracy in this setting is suboptimal.
Conclusions:
Continuous training and regular audits are recommended to improve coding quality and ensure reliable casemix data for policy and funding decisions. Clinical Trial: Not applicable
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