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Clinical Coding

Mr Buddhi PantDeputy General ManagerChildren’s ServicesSGUHT

Across England, NHS organisations are facing the challenge of delivering their commitments under the NHS Outcomes Framework within current financial constraints.

Finance managers have a critical role to play in this challenge but they cannot deliver it alone. It is clinicians – doctors, nurses and allied health professionals – who commit NHS resources and who need a greater understanding of the financial consequences of their actions.

In this context, many questions have been raised in the NHS. Not least, what do clinical and financial professionals need to be able to develop more productive partnerships? What are the barriers which the NHS needs to overcome, the key levers for engagement and the best practice steps for a way forward?

Presentation title / St George’s University Hospitals NHS Foundation Trust

Background

Clinical coding is the translation of medical terminology, as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format’ which is nationally and internationally recognised.

It is used for epidemiological and statistical purposes, as well as to determine service provision. It is also used to ensure each health care trust is paid accurately for its clinical activity by a system of Payment By Results.

Presentation title / St George’s University Hospitals NHS Foundation Trust - Mr Buddi Pant

Main Classifications

ICD-10 International Used to capture diagnostic clinical data

OPCS-4 UK specific Used to capture surgical interventions &

procedures

There is evidence that the understanding of clinical coding and indeed the background to this, structure and finances of the NHS amongst clinicians, in particular, junior doctors, is extremely poor (O’Dowd, 2013). For clinical coding to improve, clinicians must understand the significance of clinical coding and why in the current climate, it is absolutely crucial that improvements are made.

Presentation title / St George’s University Hospitals NHS Foundation Trust

Payment Process

The NHS payment regime for admitted patients (Inpatients, Daycases, Maternity, Emergency admissions) is 100% based on the clinical coding - if the coding doesn't fully reflect the patients stay they hospital won't receive the correct amount of money to cover what they did for the patient - hence pressure on coders to be as detailed and specific as possible with the coding. (the clinical codes are put through something called an HRG grouper that determines the £price) .

Presentation title / St George’s University Hospitals NHS Foundation Trust

Deadlines

These days quite a lot of time (in a good coding dept) is taken up on clinical engagement, explaining to Drs (and Medical students) what information they should ensure is written in the notes and then how what they write is translated into codes for clinical coding purposes

There are also strict deadlines to get coding done by (about 6 weeks after the patient is discharged - if that is missed the Hospital doesn't receive any money for the stay.

Presentation title / St George’s University Hospitals NHS Foundation Trust 7

Coding for Clinicians

Coding for clinicians Clinicians and coders are a team united in ensuring that

the record of patient care is accurate and timely. Clinicians can support their coders by:

writing clearly in the patient notes including all the relevant information make time for communication with coders to explain

any patient care in the notes Together they clinician and coder can improve the

quality of the patient data and so improve planning for care.

Presentation title / St George’s University Hospitals NHS Foundation Trust

Accuracy is reliant upon…

The Clinician providing the information on the patient’s diagnoses and treatment

The Clinical Coder translating that information into the appropriate coded format to reflect the patient’s hospital stay

Complete diagnostic and procedural information is vital. Hepatitis

K75.9 Inflammatory liver disease, unspecified Acute Hepatitis

K72.0 Acute and subacute hepatic failure Alcoholic Hepatitis

K70.1 Alcoholic Hepatitis

Accurate and Complete Information

1. the coding accuracy is dependent upon two sets of staff. The clinical side – providing the information The coding side – translating the medical terminology

Possible and ? Diagnoses

Chest Pain ?MI

Abdominal pain - possibly cholecystitis, possibly appendicitis

Chest pain investigations confirmed MI

Abdominal pain treated as appendicitis

1. Clinical Coding staff can only code fact. They cannot make assumptions on diagnoses or treatments. The source document must therefore clearly state diagnoses and treatments.

2. Coders are trained to interpret words as follows Possible/?: Code the presenting 'symptom, abnormal finding or problem' Probable / Presumed/ Treat As: Seek advice of the clinician or code as a

firm diagnoses. clinicians should be aware that their words are interpreted in this way.

Clinicians and Data Quality

The source documentation should: Be accurate and complete Reflect the patient’s episode of care Avoid the use of abbreviations Be clear and detailed Recording is legible and in indelible ink Include comordities / complications /

Uses of Clinical Coded Data

Clinical

Statistical

Clinical audit

Outcome

measurement

Treatment effectiveness

Cost analysis

Clinical Governance

ClinicalIndicators

Commissioning

Financial flows

Health trends

Aetiology studiesEpidemiological

studies Casemix planning

Florence Nightingale 1863"I am fain to sum up with an urgent appeal for adopting … some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life … In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of

comparison … If wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have means of ascertaining at present?"

Florence Nightingale in Notes on Hospitals, London: Longman, Green, Roberts,Longman, and Green, 1863.

How does the code Translate into HRGs (Money)

Top 15 Profit Making HRG by activity

FCE HRG (RC) FCE HRG Desc Activity

Th Income Cost

Avg (Profit) Loss

Ward Costs

PF27B Paediatric Inflammatory Bowel Disease with CC Score 0 119 1,512- 758 754- 173 PX57C Paediatric Examination, Follow-Up, Special Screening or Other Admissions, with CC Score 0 111 842- 585 257- 124 SA13B Single Plasma Exchange, Leucophoresis or Red Cell Exchange, 18 years and under 99 1,051- 689 362- 171 FZ62A Endoscopic or Intermediate, Upper Gastrointestinal Tract Procedures, between 2 and 18 years 80 1,549- 842 707- 138 PN46B Paediatric Thalassaemia with CC Score 0 70 984- 676 308- 177 PK36C Paediatric Endocrine Disorders, excluding Diabetes Mellitus, with CC Score 0 51 1,240- 668 571- 128 PK36B Paediatric Endocrine Disorders, excluding Diabetes Mellitus, with CC Score 1-3 47 1,141- 613 528- 109 DZ50Z Respiratory Sleep Study 44 939- 799 140- 273 PN48C Paediatric Blood Cell Disorders with CC Score 0 43 956- 520 436- 89 PX60C Paediatric Other Congenital Conditions with CC Score 0 32 1,096- 544 551- 84 PD14C Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis, with CC Score 4-7 26 4,343- 2,048 2,295- 616 PD14D Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis, with CC Score 2-3 26 4,145- 2,189 1,956- 729 PW18C Paediatric Minor Infections with CC Score 0 24 863- 562 302- 86 PW16D Paediatric Major Infections with CC Score 1 24 3,166- 1,879 1,287- 701 PF26C Paediatric Other Gastrointestinal Disorders with CC Score 0 24 1,103- 527 576- 98

Top 15 Loss making HRGs – Paed Medicine

FCE HRG (RC) FCE HRG Desc Activity

Th Income Cost

Avg (Profit) Loss

Ward Costs

PW19B Paediatric Viral Infections with CC Score 1-2 140 905- 1,625 720 619 PX57C Paediatric Examination, Follow-Up, Special Screening or Other Admissions, with CC Score 088 572- 1,050 478 242 PW19A Paediatric Viral Infections with CC Score 3+ 73 1,005- 2,359 1,354 931 PD12C Paediatric Asthma or Wheezing, with CC Score 0 58 820- 2,094 1,273 747 PF21A Paediatric Infectious or Non-Infectious Gastroenteritis, with CC Score 1+ 57 1,773- 4,661 2,888 1,705 PW17C Paediatric Intermediate Infections with CC Score 1-2 54 1,468- 3,429 1,961 1,333 PD15D Paediatric Acute Bronchiolitis with CC Score 0 54 1,230- 3,239 2,008 1,295 FZ64B Combined Upper and Lower Gastrointestinal Tract Diagnostic Endoscopic Procedures with Biopsy, 18 years and under50 1,493- 5,902 4,409 198 PD12B Paediatric Asthma or Wheezing, with CC Score 1-3 47 1,181- 3,448 2,267 1,387 PD14F Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis, with CC Score 0 42 1,055- 2,151 1,096 815 PF21B Paediatric Infectious or Non-Infectious Gastroenteritis, with CC Score 0 42 645- 1,723 1,078 655 PC63D Paediatric Head, Neck or Ear Disorders, with CC Score 0 36 676- 1,242 566 435 PP64B Paediatric Non-Surgical Ophthalmology with CC Score 0 35 1,118- 2,473 1,355 964 PV32C Paediatric Minor Injury without Intracranial Injury, with CC Score 0 34 549- 1,363 813 274 PD15B Paediatric Acute Bronchiolitis with CC Score 2-4 34 1,862- 3,956 2,094 1,524

Useful links

http://apps.who.int/classifications/icd10/browse/2010/en

Presentation title / St George’s University Hospitals NHS Foundation Trust