Clinical Coding

“what you need to

know”

https://www.skillsdevelopmentnetwork.com/clinical-coding

Coding for Non-Coders

“…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.”

DGCS.1: Primary diagnosis:-

The first diagnosis field(s) of the coded clinical

record (the primary diagnosis) will contain the

main condition treated or investigated during

the relevant episode of healthcare

Where a definitive diagnosis has not been

made by the responsible clinician the main

symptom, abnormal findings, or problem

should be recorded in the first diagnosis field of

the coded clinical record.

The original

mortality

indicators!!!

What is Clinical Coding?

Morbidity Coding • Acute Trusts

Mortality Coding • Office of National Statistics

Morbidity v’s Mortality

Patient admitted to hospital

Patient discharged following treatment

Case notes delivered to the coding department

Information extracted from the notes and

translated into coded format

Coded information recorded on the

hospital’s data base and submitted nationally

Clinical Coding Process

Paper based case notes, which include… Referral letters Histological and radiology results History Sheets Endoscopy reports

Supported by numerous electronic systems, such as… The Clinical Hub Cyberlab Varian Euroking

How Coders Collate the Information

Direct care

(Clinical)

Indirect

Care

(statistical)

Treatment effectiveness

Clinical audit Clinical governance

Cost analysis

Outcome measurement

Epidemiology / health trends

Research

Resource management

Commissioning

Reimbursement National Tariff/HRGs

Clinical indicators

The Importance of Why We Code

The official statistic used by NHS Digital

SHMI newest DoH measure – first published in October 2011

Published quarterly and includes deaths within 30 days of discharge

Only uses first two episodes of care

However, documentation in ALL episodes of care essential to producing accurate measure

Mortality Indicators

SHMI and HSMR use only the 1st and

sometimes 2nd Episode of Care

Single Spell of Care

Example of Patient Journey

The Clinician providing all the information re the patient’s diagnoses and treatment dated and timed, with a signature

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

Accuracy is Reliant Upon…

Accurate and complete

Reflect the patient’s episode of care

Avoid the use of abbreviations

Be clear and detailed

Documentation is legible and in indelible ink

Completed in a timely manner

Documentation Should Be…

Possible/Likely/?/rr Code as main symptoms, for example… Abdominal pain - ?appendicitis ?cholecystitis

Probable/Presumed/Treat as Code as the presumed diagnosis, for example… Probable MI or treat as UTI

Probable v’s Possible

DChS.I.1: Sepsis, septic shock, severe sepsis and neutropenic sepsis • A code that specifically classifies sepsis must always be

assigned when a patient is diagnosed with sepsis in the medical record.

• Where clinicians use terms such as urosepsis, biliary sepsis, chest sepsis, intraocular sepsis and urinary sepsis, to mean that the patient has both sepsis and a localised infection of the organ, then both conditions must be coded.

• Sepsis must not be coded where a patient only has an infection, e.g. a urinary tract infection or a chest infection without sepsis.

• Sepsis may not always be the main condition treated; therefore, sequencing of sepsis with other infections and must follow DGCS.1 Primary diagnosis (except where a standard states otherwise).

Sepsis Coding

Trust Coding Audit Coding

Primary Diagnosis I48.4 Atypical atrial flutter (Type II atrial flutter

I48.4 Atypical atrial flutter (Type II atrial flutter

Procedure 1 K62.3 Percutaneous transluminal ablation of conducting system of heart for atrial flutter NEC

K62.1 Percutaneous transluminal ablation of pulmonary vein to left atrium conducting system

Procedure 2 Y53.4 Approach to organ under fluoroscopic control

Y53.4 Approach to organ under fluoroscopic control

HRG EY31B Standard Percutaneous Transluminal Ablation of Heart with CC Score 0-2

EY30B Complex Percutaneous Transluminal Ablation of Heart with CC Score 0-2

Non-Elective Tariff £3,037 £3,949 Potential loss of income of £912

Elective Tariff £1,939 £2,909 Potential loss of income of £970

Financial Impact

Trust Coding Audit Coding

Primary Diagnosis I48.4 Atypical atrial flutter (Type II atrial flutter

I48.4 Atypical atrial flutter (Type II atrial flutter

D64.9 Anaemia, unspecified

Z93.9 Colostomy status

Procedure 1 K62.1 Percutaneous transluminal ablation of pulmonary vein to left atrium conducting system

K62.1 Percutaneous transluminal ablation of pulmonary vein to left atrium conducting system

Procedure 2 Y53.4 Approach to organ under fluoroscopic control

Y53.4 Approach to organ under fluoroscopic control

HRG EY30B Complex Percutaneous Transluminal Ablation of Heart with CC Score 0-2

EY30A Complex Percutaneous Transluminal Ablation of Heart with CC Score 3+

Non-Elective Tariff £3,949 £7,386 Potential loss of income of £3,407

Elective Tariff £2,909 £3,491 Potential loss of income of £582

Financial Impact

Trust Coding Audit Coding

Primary Diagnosis A09.9 Gastroenteritis and colitis of unspecified origin

A09.9 Gastroenteritis and colitis of unspecified origin

Diagnosis 1 E87.2 Acidosis

Diagnosis 2 E86.X Volume depletion

Diagnosis 3 E10.9 Type I diabetes mellitus

Diagnosis 4 I25.2 Old myocardial infarction

Diagnosis 5 J44.9 Chronic obstructive pulmonary disease, unspecified

HRG FZ36Q Gastrointestinal Infections without Interventions, with CC Score 0-1

FZ36N Gastrointestinal Infections without Interventions, with CC Score 5-7

Non-Elective Tariff £763 £2,437 Potential loss of income of £1,674

Elective Tariff £376 £2,142 Potential loss of income of £1,766

Financial Impact

Trust Coding Audit Coding

Primary Diagnosis I63.9 Cerebral infarction, unspecified

I63.9 Cerebral infarction, unspecified

Diagnosis 1 G81.9 Hemiplegia, unspecified Original co-morbidities, plus…

Diagnosis 2 I73.9 Peripheral vascular disease, unspecified

R33.X Retention of urine

Diagnosis 3 I10.X Essential (primary) hypertension

K59.0 Constipation

Diagnosis 4 G40.9 Epilepsy, unspecified Z50.1 Other physical therapy

Diagnosis 5 F20.9 Schizophrenia, unspecified Z50.7 Occupational therapy, NEC

Z75.1 Person awaiting admission to adequate facility elsewhere

HRG AA35E Stroke with CC Score 4-6 AA35A Stroke with CC Score 16+

Non-Elective Tariff £2,023 £11,417 Potential loss of income of £9,394

Elective Tariff £2,735 £12,129 Potential loss of income of £9,394

Financial Impact

Trust Coding Audit Coding

Primary Diagnosis

C349 Malignant neoplasm: Bronchus or lung unspecified

C349 Malignant neoplasm: Bronchus or lung unspecified

Procedure 1 E632 Endobronchial ultrasound examination of mediastinum

E632 Endobronchial ultrasound examination of mediastinum

Procedure 2 Y20.9 Biopsy of organ unspecified Y20.9 Biopsy of organ unspecified

Procedure 3 T86.5 Sampling of lymph node T86.5 Sampling of lymph node

Procedure 4 Z94.3 Left sided operation Z94.1 Bilateral operation

HRG DZ63C Major thoracic procedures, aged 19 and over, with CC Score 0-2

DZ02K Complex thoracic procedures, aged 19 and over, with CC Score 0-2

Non-Elective Tariff

£4,246 £5,411 Potential loss of income of £1,165

Elective Tariff £3,103 £5,411 Potential loss of income of £2,308

Financial Impact

Seen as a major impact on the quality of clinical coding …it is your information being translated

Clinical Engagement

Rolling audit plan:- • Clinician • Specialty based • Peer review – benchmarking data • Coder specific

Data Security & Protection Toolkit Primary diagnosis - 96.97% (required 95%) Secondary diagnosis – 96.45% (required 90%) Primary procedure – 97.64 % (required 95%) Secondary procedure - 95.67 % (required 90%)

Does the clinical record accurately reflect the patient spell?

Getting it Right First Time - GIRFT

Clinical Coding Audit

Head of Coding Jayne Lawson ext. 57387 Coding Manager Rachael Houghton ext. 55188 Coding Trainer & Auditor Tonia McLaughlin ext. 8389 Coding Auditor Rachel Ward ext. 8388 Coding Office ext. 55189

Clinical Coding Team

… IF IT ISN’T DOCUMENTED, THEN IT

DIDN’T HAPPEN

Remember