Journal of Modern Medical

Introduction
In Iran, the basis for calculating the costs of health services is the Book of Relative Values of Health Services. Despite the numerous amendments in this book, many physicians and coders believe that the coding guidelines are clinically inconsistent and too complicated; one of these complicated codes is related to the adjustment codes. In certain circumstances, it is necessary to adjust the relative value of some health services; for such cases, an adjustment code should be used, and the relative value should be included as an “adjusted relative value” in the patient’s bill. The lack of correct coding and the use of adjustment codes for any reason can lead to deductions in the invoices sent to insurance organizations.
Orthopedics is one of the most extensive and diverse surgical specialties in which most body tissues are involved. Therefore, surgeons need to apply different adjustment codes due to the variety of surgical procedures and the number of codes. Compulsion to use multiple adjustment codes increases the risk of coding errors. In addition, the coding of orthopedic surgeries requires familiarity with the coding instructions, attention to the exact anatomical issue, and the use of external or internal fixators. Some studies in Iran have shown higher errors in orthopedic procedures, but there is no study on the reasons for high errors or deductions in orthopedic surgery procedures. This study aims to investigate the causes of errors in the coding of orthopedic surgery procedures in Iran from the perspective of the people involved in the coding process of these procedures.
Methods
This is a descriptive cross-sectional study that was conducted in Ahvaz, Iran in 2020. The study population consists of orthopedic physicians, insurance experts, and revenue auditors. Using the census method, 73 samples were selected from university and non-university hospitals covered by the social security insurance in Ahvaz city. The criterion for entering the study was their familiarity with the coding of orthopedic surgery procedures using the book of Relative Values of Health Services. To collect data, two researcher-made questionnaires were used. The first questionnaire was specific to insurance experts and revenue auditors. The second questionnaire was for orthopedic physicians. The questionnaires included the following five sections: demographic information, familiarity with coding using the book of Relative Values of Health Services, how to search and select codes and control the correctness of coding, coding problems by the book of Relative Values of Health Services, and capabilities of a special coding software to help coding. To measure the answers to 35 questions (sections two, four and five), a Likert scale from 0 to 4 was used. After confirming the validity and reliability of the questionnaire, it was prepared in both paper and online forms and were provided to the participants in person or by sending their links through messengers (such as WhatsApp) or email. The collected data were analyzed using descriptive statistics (frequency, relative frequency, mean and standard deviation) in SPSS v. 22 software.
Results
In total, the highest level of familiarity with adjustment codes was related to adjustment code 51 (multiple surgeries by one or two surgeons) (64.82%) while the lowest level was related to the adjustment code 20 (independent surgery) (55.76%). Among the three study groups, insurance experts were more familiar with adjustment codes. The familiarity level of orthopedic physicians with the circulars of insurance organizations regarding orthopedic surgery codes was only 36.67%. 
Regarding the problems related to the coding of orthopedic surgery procedures based on the book of Relative Values of Health Services, it was reported that the biggest problem from among common problems in three study groups was related to the lack of an intelligent system to calculate the percentage of codes in cases with multiple codes (78.75%).According to insurance experts and revenue auditors, the biggest problem was related to the lack of punitive rules to deal with over-requesting codes. However, according to the orthopedic physicians, the most important problems were the arbitrary actions of insurance experts (88.33%) and the non-comprehensiveness of the codes and the lack of coverage of some new measures or techniques (83.33%). 
Regarding the participants’ views about the capabilities of a coding software to help coding based on the book of Relative Values of Health Services, it was found that the most important features included automatic weighting of codes if the service has multiple codes (85%), warning the user about sub-services hidden in another service (85%) and the existence of a “Help” option to guide users (85%).
Discussion
The findings of this study showed that, based on the level of familiarity with the coding instructions in the book of Relative Values of Health Services and the commonly used adjustment codes in orthopedic surgeries, as well as the weight of problems in coding orthopedic surgery procedures, the risk of error in the coding of orthopedic procedures in Iran is still high. The easiest way to solve this problem is to systematically teach the orthopedic physicians and revenue auditors about the coding instructions mentioned in the book. For this purpose, it is recommended that, in addition to including training courses about familiarity with inpatient documents and the book of Relative Values of Health Services in the residency period, the in-service training programs for employees and continuous training for orthopedic physicians be provided. All three groups of orthopedic physicians, insurance experts, and revenue auditors reported that the main problem related to the coding of orthopedic surgery procedures was the lack of an intelligent system to calculate the percentage of codes. Therefore, the next solution is to design a “coding help” module in the hospital information systems. Designing a software and expanding its features such as the possibility of searching in both Farsi and English, automatic weighting of codes if the service has multiple codes, warning the user about hidden secondary services in the main service, adding the Help option to guide users, the possibility of searching for abbreviations, as well as creating the ability to warn the user and timely update circulars and instructions sent by insurance organizations can help significantly reduce errors in the coding of surgical procedures, in addition to facilitating the coding process. It is also recommended that in order to reduce problems such as over-requesting of codes by orthopedic physicians or the arbitrary actions of insurance experts, a systematic approach should be considered to increase the interaction between insurance organizations and orthopedic physicians.

Ethical Considerations
Compliance with ethical guidelines
To comply with the principles of research ethics, the present study was submitted to the research ethics committee of Ahvaz Jundishapor University of Medical Sciences (Code: IR.AJUMS.REC.1399.268).

Funding
This study was supported by the Deputy for research of Ahvaz Jundishapor University of Medical Sciences.

Authors' contributions
Study conception and design: Javad Zarei; Data curation and analysis: AliMohammad Hadianfard; Study supervision: Ali Mohammadi; Data curation and analysis: Asma Rabiee; Writing the draft, reviewed the final version of the manuscript and approved it to submit: All authors.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the Deputy for research of Ahvaz Jundishapor University of Medical Sciences for supporting this study.


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