Introduction: The Ministry of Health (MOH) implemented the MalaysianDRG casemix system in 2010, and two national target indicators on the accuracy and completeness of clinical documentation were introduced to measure its performance. This study aims to show the trend of casemix performance in MOH hospitals and to explore the challenges in meeting these targets. Methods: The study design was sequential explanatory mixed-method design. First, a cross-sectional study described the trend of casemix performance in five MOH hospitals in Malaysia. Second, a single holistic case study of the hospital with the lowest casemix system performance was conducted to explore the perceptions of clinicians regarding the MalaysianDRG casemix and the challenges pertaining to clinical documentation. Purposive sampling was employed, and the case study data collection was carried out using in-depth-interviews, observation, and document reviews. Results: Two hospitals achieved the target in the accuracy of clinical documentation for the main condition (≥90%). For completeness in clinical documentation, four out of five MOH hospitals performed below the target (≤ 60%). Thematic analysis of the data found poor commitment of clinicians towards casemix and a multitude of obstacles in performing clinical documentations. Conclusion: After a decade of its implementation, the performance of the MalaysianDRG casemix system in MOH hospitals is still moderate due to inaccurate and incomplete clinical documentations. The study findings may be used to spread awareness and devise tailored solutions to assist clinicians in paving the way towards future excellence in MalaysianDRG casemix system.

Introduction: A casemix system measures costs of health service provision that is crucial in the planning and hospital budgeting. The MalaysianDRG casemix system has been implemented since 2010, yet many health professionals were unaware of its importance. To highlight this problem, we estimated the miscalculation of costs in providing treatment, that occurred due to inaccurate clinical documentation and coding error in the MalaysianDRG casemix system. Methods: Using a cross-sectional study design, 226 coded case notes from two healthcare institutions in Malaysia were selected and re-coded. If a difference between codes was observed, the new code would be chosen as the final code. The cases were then re-grouped using the MalaysianDRG casemix system. The cost per case derived from the new and original codes was compared. Then, the outcomes were verified by a casemix expert from the Ministry of Health. Results: Results indicated 61.9% inaccurate clinical documentation and 25.2% coding error. The difference in costs of treatment provision, due to inaccurate clinical documentation was RM227,657 and RM 68,216 for coding error. Using paired t-test analysis, differences between mean (SD) cost per case of the original vs. new codes due to inaccurate clinical documentation [RM10,208.19(12273) vs. RM11,244.53(13785.27), p<0.05], and coding error [RM10,208.19(12273.04) vs. RM11,215.52(13798.03) p<0.05] were statistically significant. These results raised important questions regarding costly financial implications arising from inaccurate clinical documentation and coding error in the MalaysianDRG casemix system. Conclusion: To achieve the full benefit of the MalaysianDRG casemix system, the quality and accuracy of its data must first be established.