Hywel Dda University Health Board - NHS Wales...Hywel Dda University Health Board P a g e | 1 1. Executive Summary It is apparent from our work that the overall accuracy of clinical

Clinical Coding Audit

Assignment Report 2013/14 Hywel Dda University Health Board

Clinical Coding Report

2013/14

Hywel Dda University Health Board

Contents

1 Executive summary ..................................................................................... 1

2 Introduction ................................................................................................... 2

3 Background .................................................................................................... 3

4 Scope & objective ....................................................................................... 4

5 Policy & process .......................................................................................... 5

6 Coding accuracy ........................................................................................... 6

6.1 Diagnoses ................................................................................................................ 6

6.1.1 Primary diagnoses ...................................................................................................... 7

6.1.2 Secondary diagnoses ................................................................................................. 8

6.2 Surgical procedures/interventions ............................................................. 10

6.2.1 Primary procedure/intervention ......................................................................... 11

6.2.2 Secondary procedure/intervention ................................................................... 12

6.3 Other coding issues .......................................................................................... 13

6.4 Payment analysis ................................................................................................ 15

Appendix A: Detailed coding assessment

Appendix B: Recommendations

Appendix C: Site analysis

Appendix D: Audit approach

Appendix E: Glossary of coding error codes

Appendix F: Assurance and risk definitions

Appendix G: Report data


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1. Executive Summary

It is apparent from our work that the overall accuracy of clinical coding is of mixed

quality with performance level that would only meet level one of Information

Governance Toolkit (IG) Requirement 505 (NB. The Health Board is not required to

submit IG Toolkit levels, and this is used purely as a means of benchmarking). The

coding of the primary diagnosis was very good, but the accuracy of primary procedure

fell 2.42% short of level two standards. The accuracy of the clinical coding is shown

below:

CODING FIELD PERCENTAGE

CORRECT

IG REQ 505

LEVEL 2

IG REQ 505

LEVEL 3

Primary diagnosis 92.86% 90% 95%

Secondary diagnosis 84.88% 80% 90%

Primary procedure 87.58% 90% 95%

Secondary procedure 83.33% 80% 90%

Good practice was noted in relation to the support the clinical coding function

receives across the Health Board, with dedicated time provided for training, as well as

the funding of a clinical coding auditor.

While there are there are a number of opportunities to improve processes which will

further improve accuracy as described within Appendix A, as a result of our findings

the assurance level which we are able to provide in respect of clinical coding and

underlying processes is:

SIGNIFICANT ASSURANCE


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2. Introduction

Accurate data quality and clinical coding are imperative to support patient care and

to ensure the information is used for improving healthcare as well as contributing to

effective management.

To provide consistently recorded data, well-defined standards must be applied to

allow comparisons to be made across time and between sources. The NHS uses the

International Statistical Classifications of Diseases and Related Health Problems, Tenth

Revision (ICD-10) and the Office Population Censuses and Surveys of Surgical

Operations and Procedures, Fourth Revision (OPCS-4) as the standards for diagnostic

and procedural coding. The data may be derived from Clinical Terms (the Read

codes). The classifications provide the framework, using rules and conventions that,

when applied accurately result in the provision of high quality, statistically meaningful

data.

Although Wales are not required to submit audit results for Information Governance

(IG) purposes the Health Board decided that they would find benefit in following the

guidelines as set out by IG Toolkit Requirement 505. IG Toolkit Version 11.0 was

launched in April 2013 and, within that framework, requirement 505 states that trusts

should have:-

established documented procedures for the regular audit of clinical coding;

carried out an internal clinical coding audit programme within the last twelve

months which was based on the requirements and standards within the latest

version of NHS Clinical Coding Audit Methodology and must have been

undertaken by staff on the registered list of clinical coding auditors; and,

where required, had an external clinical coding audit commissioned by the

Audit Commission.

This report provides an appraisal on the current position of Hywel Dda University

Health Board in adhering to national clinical coding standards. The audit was based

on the methodology detailed in the NHS Clinical Coding Audit Methodology Version

7.0.


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3. Background

The Health Board deals with approximately 112,211 finished consultant episodes

(FCEs) per year, which are all coded by the clinical coding staff using ICD-10 and

OPCS-4 to generate clinical information of inpatient activity. This is broken down

across site as follows:

Site Finished consultant episodes

Glangwili General Hospital 41,775

Prince Philip Hospital 19,450

Withybush General Hospital 32,230

Bronglais General Hospital 18,756

The coders, who are part of a centralised Clinical Coding Department within Planning

and Performance, are responsible for the entire coding process, from abstraction

through to input.

There are 21.01 whole time equivalent (WTE) clinical coders, inclusive of the Clinical

Coding Manager and Supervisors. The clinical coding function across the four sites is

made up from 25 coding staff, 10 of whom are accredited clinical coders (ACCs). The

Clinical Coding Manager has responsibility across the four sites; there are Supervisors

at two of the sites; the Health Board also employs a registered Clinical Coding Auditor,

who assisted with the audit.

The Health Board works to a formula for staffing levels of 6,600 FCEs per WTE. On

the surface the current staffing is working to 5,340 FCEs per WTE, but the Clinical

Coding Manager, Supervisors and Auditor do not have a full clinical coding workload

to account for their other responsibilities.

The source document used for the extraction of clinical coding data at the Health

Board is the case note, supported by a discharge summary and proforma.


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4. Scope & objective

To measure the quality of the clinical coding within the Health Board and to assist in

improving the quality of clinical coding the objectives of the audit were:-

To assess how well the coded data accurately reflects the diagnosis and

procedures described in the clinical records;

To focus on cardiology and general surgery with a portion of the sample

covering miscellaneous specialties;

To benchmark the accuracy against standards set out Information Governance

Toolkit Requirement 505;

To determine if the coding team thoroughly reviews appropriate source

documents;

To report errors in clinical coding assignments;

To identify sources of clinical coding errors and make recommendations for

correction;

To identify any clinical coding training requirements;

To determine the quality of the source documentation for the clinical

coding function;

To promote interchange between clinician and coder to improve the quality

of coded data; and

To further promote interaction with the Information Department, Finance

Department and other function leads.


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5. Policy & process

The Department has a Policy and Procedure document in place that is well structured,

and supports the management and provision of information to all of the clinical

coders via a shared drive. The document was last reviewed and updated in October

2013 and remains current.

The Health Board uses the Medicode encoder; one issue relating to this is the re-

sequencing of procedure codes when they are transferred from Medicode into the

Myrddin Patient Administration System.

The clinicians actively engage in the clinical coding process through various avenues.

In Withybush General Hospital the clinicians validate the main diagnosis, and partially

validate other diagnoses and procedures against the discharge letter. Elsewhere, the

Clinical Coding Manager liaises with senior clinicians in the Health Board who have

clinical roles in Informatics. Also the coders have access to clinicians to query clinical

information and to ask advice about conditions and procedures.

The Department has a programme of data quality accuracy checks that incorporate

clinical coding; audits are performed monthly, if there are no staffing issues.

The last external audit was carried out in 2010.


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6. Coding accuracy

6.1. Diagnoses

Diagnostic information is required for the recording of both primary and secondary

diagnoses for each episode of care. The definition of a primary diagnosis is:

"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

consultant the main symptom, abnormal finding or problem should be

recorded in the first diagnosis field of the coded clinical record"1.

Therefore, on discharge the patient should be assigned a primary diagnosis even if a

definitive diagnosis is not available. In addition to the primary diagnosis, all relevant

secondary diagnoses should be recorded on the discharge front sheet. Secondary

diagnoses should include:

Conditions or problems dealt with during the episode of care

Conditions, which pre-exist in the patient

Patient status e.g. dependence on dialysis, etc.

The secondary diagnoses should be recorded in order to accurately reflect the care

received by the patient.

1 NHS Executive Health Service Guidelines HSG (96) 23 20 September 1996


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6.1.1. Primary diagnoses

Of the 252 episodes audited 234 (92.86%) primary diagnoses were coded correctly

with errors categorised as depicted and detailed below.

Figure 1 – Primary diagnosis coding analysis and error types

The agreed errors that were identified in the audit comprised of:

Non-coder errors (errors that are outside of the coders control and related to the

documentation provided or a procedure in place)

i. On one (0.40%) occasion the primary diagnosis was incorrect due to

information being available to the auditor that was not available at the time

of coding (PDI).

Coder errors

ii. One (0.40%) primary diagnosis was incorrect at three-character level (PD3).

iii. On four (2.78%) occasions the primary diagnosis was incorrect at fourth

character level (PD4).

iv. On two (0.79%) occasions the condition the auditor deemed to be the

primary diagnosis had been recorded by the coder but not sequenced in the

primary position (PDIS).

v. There were seven (2.78%) omitted primary diagnoses noted by the auditor

(PDO).

234

1

17

Primary diagnoses

Correct

Non-coder error

Coder error


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6.1.2. Secondary diagnoses

It is important that all relevant secondary diagnoses are recorded accurately in order

to reflect the care provided to the patient during the relevant episode of care.

Secondary diagnoses recorded should include additional conditions and

complications arising during an episode of care, and pre-existing conditions, which

require the continuing care of the patient during their episode of care.

Of the 853 valid secondary diagnoses 724 (84.88%) were coded correctly with errors

categorised as depicted and detailed below.

Figure 2 - Secondary diagnosis coding analysis and error types


Non-coder errors

vi. Eight (0.94%) secondary diagnoses were incorrect due to information being

available to the auditor that was not available at the time of coding (SDI).

Coder errors

vii. Eight (0.94%) secondary diagnoses were incorrect at three-character level

(SD3).

viii. On 16 (1.88%) occasions the secondary diagnosis was incorrect at fourth

character level (SD4).

ix. On 94 (11.02%) occasions a secondary diagnoses was omitted (SDO).

724

8 142

Secondary diagnosis

Correct

Non-coder error

Coder error


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x. There were 18 unnecessary secondary diagnosis codes assigned (SDNR).

xi. One (0.12%) external cause code was recorded incorrectly (ECI).

xii. Two (0.23%) external cause codes had been omitted (ECO).

xiii. Three unnecessary external cause codes had been recorded (ECNR).


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6.2. Surgical procedures/interventions

Information regarding surgical procedures / interventions undertaken is required for

every relevant episode of patient care, and should be documented on the discharge

front sheet by the clinical staff responsible for the patient.

According to OPCS-4.62, the definition of an intervention is: "...those aspects of clinical

care carried out on patients undergoing treatment:-

for the prevention, diagnosis, care or relief of disease;

for the correction of deformity or deficit, including those performed for cosmetic

reasons;

associated with pregnancy, childbirth or contraceptive or procreative

management.

Typically this will be:

surgical in nature; and/or

carries a procedural risk; and/or

carries an anaesthetic risk; and/or

requires specialist training; and/or

requires special facilities or equipment only available in an acute care setting”

It is generally considered that the procedure / intervention of most relevance should

be selected as the primary procedure i.e. the main surgical operation in terms of

complexity and use of resources.

Secondary procedures / interventions are considered to include supplementary

procedures / interventions such as diagnostic procedures or which are less complex

than the main procedure.

2 OPCS Classification of Interventions and Procedures Version 4.6, TSO page viii


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6.2.1. Primary procedure/intervention

Of the 161 valid primary procedures 141 (87.58%) were coded correctly with errors


Figure 3 - Primary procedure coding analysis and error types


Coder errors

xiv. Three (1.86%) primary procedures were incorrect at three-character level

(PP3).

xv. Four (2.48%) primary procedures were incorrect at fourth character level

(PP4).

xvi. On two (1.24%) occasions the primary procedure described by the auditor

had been recorded but not sequenced in the primary position (PPIS).

xvii. On 11 (6.83%) occasions the primary procedure was omitted (PPO).

xviii. Two unnecessary primary procedures had been recorded (PPNR).

141

1 22

Primary procedure

Correct

Non-coder error

Coder error


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6.2.2. Secondary procedure/intervention

Of the 312 valid primary procedures 260 (83.33%) were coded correctly with errors


Figure 4 - Secondary procedure coding analysis and error types


Non-coder errors

xix. One (0.32%) secondary procedure was incorrect due to information being

available to the auditor that was not available at the time of coding (SPI).

Coder errors

xx. Five (1.60%) secondary procedures were incorrect at three-character level

(SP3).

xxi. On 11 (3.53%) occasions the secondary procedure was incorrect at fourth

character level (SP4).

xxii. One (0.32%) secondary procedure had been sequenced in a way that

contravened a national clinical coding standard (SPIS).

xxiii. On 34 (10.90%) occasions a secondary procedure code had been omitted

(SPO).

xxiv. 10 unnecessary secondary procedure codes had been recorded (SPNR).

260

161

Secondary procedure

Correct

Non-coder error

Coder error


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6.3. Other coding issues

The Health Board performed to a mixed standard on audit, and from such a

generalised audit the only concerns highlighted were:

The auditors found a large number of omitted secondary diagnoses; contributing the

more than any other error type found in the audit. These were all relevant to the

episode of care with many relating to a national standard or classification rule.

Information on endoscopy reports was occasionally misinterpreted, with incidental

findings recorded as the primary diagnosis rather than the reason for the

investigation, for example, a person investigated for weight loss having haemorrhoids

being coded as the primary diagnosis when the report stated that this was not the

cause. There were other occasions noted when incidental findings were not recorded.

A standard3 was introduced to clarify the use of fifth characters in Chapter XIII

Disorders of the musculoskeletal system and connective tissue. This states that their

use is “mandatory where the data is present in the medical record, and where doing

so adds more specific information”. A fifth character of ‘9’ was regularly assigned

when the site of involvement was not known, but this is not deemed necessary.

Medicode does bring up a command to assign a fifth character, but this can be

bypassed by the coder.

There were occasions when a diagnosis of ‘left ventricular systolic dysfunction’ (or

‘LVSD’ as it is abbreviated) was coded to I50.1 Left ventricular failure. The term itself

cannot be trailed and the diagnosis is not uniformly accepted as a heart failure, and

thus without a local policy to support it cannot be coded as such.

The documentation relating to haemorrhoids was poor and never specified whether

they were internal or external. The terminology used described the haemorrhoids by

degree and position; information found supported that this related to haemorrhoids

but there are no standards or local policies to support this.

The recording of anaesthetics was regularly omitted or coded as unspecified when a

specified type was documented, particularly Midazolam. It is a Welsh standard to

record anaesthetics and a local policy to record Midazolam to Y84.8 Other

anaesthetic, other specified.

3 ‘National Clinical Coding Standards ICD-10 4th Edition (2013)’ reference book – XIII-1


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It is a national clinical coding standard4 to record transthoracic echocardiograms (TTE)

whenever they are performed on inpatient episodes. It further confirms that a clinical

statement of ‘echocardiogram’ or ‘echo’ without further specification is coded to

U20.1 Transthoracic echocardiogram. TTEs being omitted from the coding record

across all sites made up 10 of the omitted procedures.

There were a number of occasions when angiocardiography procedures were coded

with Y53.4 Approach to organ under fluoroscopic control assigned in a supplementary

position without the method being specified in the medical record. There was no

local policy employed for this, and as such should have been coded to Y53.9

Unspecified approach to organ under image control.

There were a number of occasions when Y79.3 Transluminal approach to organ

through femoral artery was assigned to supplement a code for an angiocardiography.

There is no standard to state that this should not be coded but the guidance in the

OPCS-4.6 Instruction Manual5 indicates that this category is only intended to be

assigned for transcatheter aortic valve implantation (TAVI) procedures.

4 OPCS-4.6 Clinical Coding Instruction Manual – U-15 5 OPCS-4.6 Clinical Coding Instruction Manual – Y-23


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6.4. Payment analysis

Payment Pre-

audit

Payment Post-

audit

Gross financial

change

Net Financial

change

Number of

episode UTAs

£283,611 £290,011 £9,428 £6,400 17

These figures are based on the English Payment by Results system that processes

funding through the tariff attached to Healthcare Resource Groupings. This

information is used purely as an indication of the impact of the clinical coding

and not related to the funding that Hywel Dda University Health Board received.

The data is comparative and may not be fully compliant with all requirements

of the Payment by Results mechanism.


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A p p e n d i x | A.1

Appendix A: Detailed coding assessment

Ref Record

ID

Diagnosis Health

Board

code

Audit

Code

Diagnosis Error

Type

Rationale Financial

implication

Primary diagnoses

i 191315 Cystocele N811 N814 Uterovaginal prolapse,

unspecified

PDI Coded from urodynamics sheet only. Other

documentation stated that the patient had a

uterine prolapse.

£0

ii 191315 Gastroenteritis and

colitis of unspecified

origin

A099 A080 Rotaviral enteritis PD3 Stool sample came back as rotavirus four

days post discharge, which the coders would

have had access to.

£0

iii 189925 Left ventricular failure I501 I500 Congestive heart failure PD4 States that the patient has "biventricular

failure", which trails to I50.0.

£0

iv 191169 Unspecified acute lower

respiratory infection

J22X J440 Chronic obstructive

pulmonary disease with

acute lower respiratory

infection

PDIS The patient had COPD and a chest infection,

which is linked to J44.0 and does not require

the J22.X, in accordance with the national

standards.

-£187

Chronic obstructive

pulmonary disease with

acute lower respiratory

infection

J440 - --- SDNR


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Ref Record

ID

Diagnosis Health

Board

code

Audit

Code

Diagnosis Error

Type

Rationale Financial

implication

v 192249 Chronic obstructive

pulmonary disease,

unspecified

J449 K219 Gastro-oesophageal

reflux disease without

oesophagitis

PDO The patient was admitted for an OGD due to

reflux disease, which had not been coded.

£0

Secondary diagnoses

vi 189847 --- - I209 Angina pectoris,

unspecified

SDI The patient was having an angio-

cardiography because of worsening angina.

This was not mentioned on the

angiocardiography form, and the coders

don't have access to notes for these

investigations.

£0

vii 192433

Aortic valve disorder,

unspecified

I359 I080 Disorders of both mitral

and aortic valves

SD3 Patient has aortic and mitral regurgitation,

which was documented in the notes but not

reflected in the coding.

£0

viii 192361 Left ventricular failure I501 I518 Other ill-defined heart

diseases

SD4 Left ventricular failure was never confirmed,

only left ventricular systolic dysfunction. The

Health Board does not have a policy to code

this diagnosis in such a way.

£0

ix 192401 --- - Z539 Procedure not carried

out, unspecified reason

SDO The patient was admitted for a direct current

cardioversion, but this was cancelled.

-£722


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Ref Record

ID

Diagnosis Health

Board

code

Audit

Code

Diagnosis Error

Type

Rationale Financial

implication

x 189881 Other aortic valve

disorders

I358 - --- SDNR Aortic sclerosis was noted on echo-

cardiogram, but this was not carried out until

the next episode.

£0

xi 191226 Intentional self-

poisoning by and

exposure to

antiepileptic, sedative-

hypnotic,

antiparkinsonism and

psychotropic drugs, not

elsewhere classified -

Home

X610 X619 Intentional self-

poisoning by and

exposure to

antiepileptic, sedative-

hypnotic,

antiparkinsonism and

psychotropic drugs, not

elsewhere classified -

Unspecified place

ECI The medical record does not state where

overdose took place.

£0

xii 191214 Hypo-osmolality and

hyponatraemia

E871 E222 Syndrome of

inappropriate secretion

of antidiuretic hormone

SD3 The hyponatraemia was due to SIADH, which

was secondary to sertraline.

£0

--- - Y492 Drugs, medicaments

and biological

substances causing

adverse effects in

therapeutic use - Other

and unspecified

antidepressants

ECO


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Ref Record

ID

Diagnosis Health

Board

code

Audit

Code

Diagnosis Error

Type

Rationale Financial

implication

xiii 192287 Drowning and

submersion while in

swimming-pool - Sports

and athletics area

W673 - --- ECNR The external cause code had been

unnecessarily repeated.

£0

Primary procedure/intervention

xiv 191196 Diagnostic fibreoptic

endoscopic examination

of upper gastro-

intestinal tract -

Unspecified

G459 G448 Other therapeutic

fibreoptic endoscopic

operations on upper

gastrointestinal tract -

Other specified

PP3 The scope was used to unblock the stent,

which is a form of therapeutic procedure and

should have been reflected as such in the

coding.

£0

xv 189772 Diagnostic fibreoptic

endoscopic examination

of upper

gastrointestinal tract -

Unspecified

G459 G451 Fibreoptic endoscopic

examination of upper

gastrointestinal tract

and biopsy of lesion of

upper gastrointestinal

tract

PP4 It stated on the endoscopy sheet that they

took a cold biopsy from duodenum, which

was not reflected in the primary procedure

code.

+£79

xvi 191215 Excision or biopsy of

axillary lymph node

T873 B274 Total mastectomy NEC PPIS There is an issue with Medicode, which

altered the sequence of the procedure codes

into chronological order. The coder can

change them back, but they had not on this

occasion.

+£592

Total mastectomy NEC B274 T873 Excision or biopsy of

axillary lymph node

-


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Ref Record

ID

Diagnosis Health

Board

code

Audit

Code

Diagnosis Error

Type

Rationale Financial

implication

xvii 191158 --- - U201 Transthoracic

echocardiography

PPO The patient had an echocardiogram, which

must be recorded in accordance with national

clinical coding standards, but had not been.

£0

xviii 192401 Direct current

cardioversion

X501 - --- PPNR The patient was admitted for a DC

cardioversion, but this was cancelled.

£0

Secondary procedure/intervention

xix 189929 --- - Y829 Local anaesthetic -

Unspecified

SPI Anaesthetic not specified on documentation

used by the coder.

£0

xx 189942 Rubber band ligation of

haemorrhoid

H524 L703 Ligation of artery NEC SP3 The patient underwent a haemorrhoidal

artery ligation operation (HALO) procedure,

which has a national standard that must be

adhered to, which had not been on this

occasion.

£0

xxi 189873 Approach to organ

under fluoroscopic

control

Y534 Y539 Approach to organ

under image control -

Unspecified

SP4 Method of image control was not specified as

fluoroscopic.

£0


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Ref Record

ID

Diagnosis Health

Board

code

Audit

Code

Diagnosis Error

Type

Rationale Financial

implication

xxii

191194 Computed tomography

NEC

U212 U212 Computed tomography

NEC

All of the codes for the CT scan were

recorded, but there is a precise sequencing

standard that states that the Y98 must follow

the Y97 code.

£0

Radiology with post-

contrast

Y973 Y973 Radiology with post-

contrast

Chest NEC Z924 Y983 Radiology of three body

areas (or twenty–forty

minutes)

SPIS

Radiology of three body

areas (or twenty–forty

minutes)

Y983 Z924 Chest NEC

Abdomen NEC Z926 Z926 Abdomen NEC

Pelvis NEC O161 O161 Pelvis NEC

xxiii 190022 --- - Y84.8 Other anaesthetic -

Other specified

SPO The coding of anaesthetic is a national

standard, and the Health Board have a policy

to record sedation with specified drugs,

which had not been omitted.

£0

xxiv 190063 Creation of temporary

ileostomy

G742 G751 Refashioning of

ileostomy

PP3 The ileostomy was stated to have been

'revised’ and 'refashioned'; the lead term

refashioning is indexable and would cover the

creation of a new ileostomy and the revision

of the original ileostomy.

£0

Closure of ileostomy G753 - --- SPNR

Revisional operations

NOC

Y713 - --- SPNR


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A p p e n d i x | C.1

Appendix B: Recommendations

1. Training

Issue Identified – There were a number of issues identified during the audit relating to the

interpretation of the information contained in the medical record and/or the national

standard that relate to it. The particular areas that were routinely identified by the auditors

were:

Co-morbidities were regularly omitted from the coding. This related to conditions that

impacted on the patient’s healthcare, and regularly to classification standards. Omitted

co-morbidities were the most common error type identified.

Endoscopy reports were often misinterpreted, with the primary diagnosis recorded by

the coder often being an incidental finding and not the reason for the investigation. In

addition the adherence to national standards relating to endoscopies was not always

followed.

The omission of transthoracic echocardiograms when they were clearly documented in

the medical record; this issue was identified at all sites;

The coding of anaesthetics is a standard in Wales, and must be coded when it is

documented; as well as this there is a local policy for the coding of Midazolam. These

were regularly omitted.

Risk Rating – Medium

Recommendation – The Health Board should conduct a series of short training sessions over

the following weeks to ensure that issues highlighted on audit are addressed with the clinical

coders. This will provide a forum for coders to consolidate their understanding and ask

questions to clarify the standards.

This should be followed up with internal audit one to two months later on the areas

addressed to ensure that these sessions have improved the quality of the clinical coding.


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2. Utilisation of in-house auditor

Issue Identified – The Health Board has supported the training of an in-house Clinical Coding

Auditor. The requirements of maintaining an auditor registration means that a significant

amount of their time needs to be spent on coding tasks. The Health Board to this point have

continued to support this by providing time to carry out these tasks. The support of this role

should support the continued improvement of the data quality of the coding function.


Recommendation – The Health Board should continue to support the in-house Clinical

Coding Auditor’s utilisation. Over time this could be increased to incorporate working with

directorates and clinicians to identify areas where the coding and information provided to

support it could be improved. This in turn will lead to increased awareness and respect for

the function and promote a general desire to support each function in producing quality

information.


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3. Discuss Medicode issues with system developer

Issue Identified – There were a number of occasions when the auditors found errors in the

sequence of procedures, which meant the most resource intensive procedure was sequenced

in a secondary position. This was particularly the case with diagnostic procedures being

sequenced in a primary position ahead of therapeutic. On discussion it would appear this is

a known issue with the Medicode encoder, which re-sequences procedure codes into

chronological order when transferred to the Myrddin Patient Administration System. The

coders can alter the sequence on Myrddin but this is a waste of resource, as well as there

being potential to forget to do it.


Recommendation – The Health Board should discuss the issue with 3M, the suppliers of

Medicode, at the earliest opportunity and ask for a patch to be written to prevent this issue

from continuing.

In the interim the Clinical Coding Manager should highlight this finding to the clinical coders

and ask them to be vigilant in ensuring that, before finalisation, the procedure codes are

sequenced in the correct position.


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4. Local policy

Issue Identified – There were a number of occasions when the clinical coding was coded to

a more specific code than what was documented in the medical record. This indicated that

the coders were aware of the method used for particular procedures but this was not

supported in the record or through the use of local policies. This was particularly relevant

for angiocardiography procedures that were consistently coded with a supplementary code

to reflect it was carried out under fluoroscopic image guidance.

It was also noted by the auditors that the quality of information provided for care of

haemorrhoids was poor. The detail was often limited and used terminology that cannot be

reflected in the clinical coding without the use of local policies.

Risk Rating – Low

Recommendation – The Clinical Coding Manager should discuss these and any other

applicable areas with the relevant clinicians and/or directorates to ensure that local policies

can be implemented, where needed, to improve the quality of the clinical coding.

These local policies should be implemented as soon as possible to avoid them being flagged

as errors in future audits. In addition they should have set review dates to ensure they

continue to reflect current practice and be signed off as understood by all relevant clinical

coders.


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5. Query the use of Y79

Issue Identified – The auditors noted that Y79.3 Transluminal approach to organ through

femoral artery was assigned in supplementary position following a code for an

angiocardiography. There is no standard to state that this should not be coded but the

guidance in the OPCS-4.6 Instruction Manual indicates that this category is only intended to

be assigned for transcatheter aortic valve implantation (TAVI) procedures.

Risk Rating – Low

Recommendation – The Health Board should send a query to the Welsh Standards Service

Desk to establish whether there is a requirement to assign the Y79.3 code following this

procedure or whether this is superfluous to the record. The resolution will then dictate

whether they should continue to assign the code in this way or to omit it in the future.


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Appendix C: Site analysis

Prince Philip Hospital

Primary diagnoses

Number of episodes Number correct Percentage

53 49 92.45

Coder Error Number Percentage

PD4 2 3.77

PDO 2 3.77

Secondary diagnoses

Number of valid

diagnoses

Number correct Percentage

207 185 89.37

Non-coder Error Number Percentage

SDI 6 2.90


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SD3 3 1.45

SD4 3 1.45

SDO 10 4.83

SDNR 7 -



37 37 100.00



78 69 88.46


SPI 1 1.28


SP3 1 1.28

SP4 2 2.56

SPO 5 6.41

Glangwili General Hospital


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Primary diagnoses


73 66 90.41


PD3 1 1.37

PD4 2 2.74

PDIS 1 1.37

PDO 3 4.11

Secondary diagnoses


234 187 79.91


SDI 1 0.43


SD3 2 0.85

SDO 44 18.80

SDNR 5 -



2013/14




50 42 84.00


PP3 1 2.00

PP4 2 4.00

PPIS 1 2.00

PPO 4 8.00



98 78 79.59


SP3 3 3.06

SP4 6 6.12

SPO 11 11.22

SPNR 5 -


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Withybush General Hospital

Primary diagnoses


76 70 92.11


PDI 1 1.32


PD4 3 3.95

PDIS 1 1.32

PDO 1 1.32


2013/14



Secondary diagnoses


167 131 78.44


SDI 1 0.60


SD3 1 0.60

SD4 4 2.40

SDO 27 16.17

SDNR 2 -

ECI 1 0.60

ECO 2 1.20


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49 42 85.71


PP3 1 2.04

PP4 2 4.08

PPIS 1 2.04

PPO 3 6.12

PPNR 1 -



99 82 82.83


SP3 1 1.01

SP4 2 2.02

SPIS 1 1.01

SPO 13 13.13

SPNR 3 -


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Bronglais General Hospital

Primary diagnoses


50 49 98.00


PDO 1 2.00

Secondary diagnoses


236 212 89.83


SD3 2 0.85

SD4 9 3.81

SDO 13 5.51

SDNR 4 -

ECNR 3 -


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26 21 80.77


PP3 1 3.85

PPO 4 15.38

PPNR 1 -



37 31 83.78


SP4 1 2.70

SPO 5 13.51

SPNR 2 -


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Appendix D: Audit approach

The audit was based on the NHS Clinical Coding Audit Methodology Version 7.0 and the Code

of Best Practice for Clinical Coding Auditors. The documents provide guidance on conducting

a clinical coding audit.

Codes on CDS were considered accurate if they described the actual condition of the patient

(and any procedures performed) as completely as possible within the constraints of the

classifications used.

The three dimensions of the coding accuracy are:

Individual codes: are they an accurate reflection of the clinical statement?

Totality of codes: do they represent all the relevant clinical details?

Sequencing of codes: are the codes in the correct sequence as defined by

the rules and conventions of the classification, and the mandated definition

of a primary diagnosis?

Coding errors were then evaluated as follows:

- Incorrect main diagnosis selected

- Incorrect three character category

- Incorrect fourth character category

- Omission of diagnosis / procedure codes

- Unnecessary codes

- Incorrect sequencing of diagnostic / procedure codes

Accurate coded information is essential for many areas of accountability in the NHS.

Information derived from clinical coding is used in many areas at secondary and primary care,

strategic health authority and national level to analyse performance and levels of achievement,

to support the government's national initiatives to improve service quality and deliverance

through Payment by Results, clinical indicators and clinical governance.

However, all information for coding purposes is derived from the information provided by the

clinical staff responsible for the patient. It is therefore essential that all information recorded

in the patient’s medical record be documented clearly, accurately and completely.


2013/14



The audit did not concentrate solely on the accuracy of the coding, but also on other factors

influencing the coding process. Without studying the wider picture of how information is

created for coding purposes, one cannot expect to attain a realistic picture of the factors that

determine the accuracy of coding.

Other areas studied during the audit included:

Documentation issues:

Document incomplete

Documentation inconsistent, unclear

Terminology unclear

Information regarding the episode not available in the

clinical records

Lack of clear procedures for coding and abstraction

Lack of procedures for reviewing clinical records

Coded to consultant specification (resulting in a contravention of a

coding rule/convention or standard)

The error keys used were based on those outlined in NHS Clinical Coding Audit

Methodology Version 7.0 (Appendix D).

The auditors documented any discrepancies found using the appropriate audit worksheets. A

first draft of the audit report including findings, conclusions and recommendations of the

audit was submitted to the Health Board for review.

The auditors also checked the accuracy of a subset of key data items for Admitted Patient

Care. These were:

Start date (episode)

End date (episode)

Secondary diagnosis (ICD)

Primary procedure (OPCS)

Procedure date (primary)


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A p p e n d i x | D.1

Appendix E: Glossary of coding error codes

Unsafe to Audit Error Key

UTA UNSAFE TO AUDIT

The auditor is unable to audit the coded clinical data against the source documentation.

For example, there is insufficient or no information regarding the episode in the auditor’s

source documentation.

Primary Diagnosis Error Key

Coder Error

PD3 PRIMARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL

The primary diagnosis code has been allocated to an incorrect three character.

PD4 PRIMARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL

The primary diagnosis code has been allocated to an incorrect fourth character.

PD5 PRIMARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL

The primary diagnosis code has been allocated to an incorrect fifth character.

PDIS PRIMARY DIAGNOSIS INCORRECTLY SEQUENCED

The primary diagnosis code recorded by the auditor has not been sequenced by the coder

as the primary diagnosis.

PDO PRIMARY DIAGNOSIS OMITTED

The primary diagnosis recorded by the auditor has not been recorded by the coder in any

diagnosis field.

Non-Coder Error

PDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF

CODING

Information available to the auditors was not available at the time of coding. This is where

information regarding the episode became available after the episode was coded. This

error key is not to be used if the information was not accessed by the clinical coder at the

point of coding, for example, with histopathology reports.

This error key would also be assigned by the auditor when the source documentation used

at the time of coding did not contain all pertinent information required for accurate and

complete coding and the coder did not have access to this information, for example,

coding from pro-forma with no access to the casenotes.

PDD PRIMARY DIAGNOSIS DOCUMENTATION ISSUE

The auditor is unable to code the clinical data from the source documentation and

compare against that of the Health Board’s due to unclear or inconsistent information.

For example:

Inconsistency between information recorded by clinical staff contained on the source

documentation and it is not clear which is correct

The source documentation is illegible.


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PDM PRIMARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION

There is a clear and documented directive from management to contravene coding to

national standards.

For example:

by unbundling diagnoses or procedures into component parts

by adding or optimising the coded clinical data to alter the derived HRG.

PDC PRIMARY DIAGNOSIS CODED TO CONSULTANT SPECIFICATION

There is a clear and documented directive from clinicians to contravene coding to national

standards or capture those instances where a clinician has requested that coding be done

in a particular way as it more accurately captures a diagnosis.

For example, by unbundling diagnoses or procedures into component parts.

PDSC PRIMARY DIAGNOSIS INCORRECT DUE TO SYSTEM CONSTRAINT

Due to the system that the Organisation uses the primary diagnosis code is technically

incorrect at some level, omitted or sequenced incorrectly.

Secondary Diagnosis Error Key

Coder Error

SD3 SECONDARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL

The secondary diagnosis code has been allocated to an incorrect three character.

SD4 SECONDARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL

The secondary diagnosis code has been allocated to an incorrect fourth character.

SD5 SECONDARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL

The secondary diagnosis code has been allocated to an incorrect fifth character.

SDNR SECONDARY DIAGNOSIS NOT RELEVANT

The secondary diagnosis recorded by the coder is not relevant to the episode of care.

SDO SECONDARY DIAGNOSIS OMITTED

The secondary diagnosis has been recorded by the auditor as relevant but is missing from

the Organisation’s recorded episode.

SDIS SECONDARY DIAGNOSIS INCORRECT SEQUENCING

The sequence of the secondary diagnosis codes contravenes national standards. This error

key can only be assigned for error in the following national standards:

1. Outcome of delivery (Z37 and Z38 if not well baby)

2. Asterisk codes must be preceded by a dagger code

3. Specific coding conventions in ICD-10 i.e. use additional code

4. Extent of body surface in burns (T31, T32).

ECI EXTERNAL CAUSE CODE INCORRECT

The external cause code recorded by the Organisation is incorrect at any character level.

ECO EXTERNAL CAUSE CODE OMITTED

The external cause code has been omitted from the Organisation’s recorded episode.

ECNR EXTERNAL CAUSE CODE NOT RELEVANT

The external cause code recorded by the coder is not relevant to the episode of care.

Non-Coder Error


2013/14



SDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF

CODING









SDD SECONDARY DIAGNOSIS DOCUMENTATION ISSUE



For example:




SDM SECONDARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION


national standards.

For example:



SDC SECONDARY DIAGNOSIS CODED TO CONSULTANT SPECIFICATION





SDSC SECONDARY DIAGNOSIS INCORRECT DUE TO SYSTEM CONSTRAINT

Due to the system that the Organisation uses the secondary diagnosis code is technically


Primary Procedure Error Key

Coder Error

PP3 PRIMARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL

The primary procedure code has been allocated to an incorrect three character.

PP4 PRIMARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL

The primary procedure code has been allocated to an incorrect fourth character.

PPIS PRIMARY PROCEDURE INCORRECTLY SEQUENCED

The primary procedure code recorded by the auditor has not been sequenced by the coder

as the primary procedure.

PPO PRIMARY PROCEDURE OMITTED

The primary procedure recorded by the auditor has not been recorded by the coder in any

procedure field.


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PPNR PRIMARY PROCEDURE NOT RELEVANT

The primary procedure recorded by the coder is not relevant to the episode of care.

Non-Coder Error

PPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF

CODING









PPD PRIMARY PROCEDURE DOCUMENTATION ISSUE



For example:




PPM PRIMARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION


national standards.

For example:



PPC PRIMARY PROCEDURE CODED TO CONSULTANT SPECIFICATION





PPSC PRIMARY PROCEDURE INCORRECT DUE TO SYSTEM CONSTRAINT

Due to the system that the Organisation uses the primary procedure code is technically


Secondary Procedure Error Key

Coder Error

SP3 SECONDARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL

The secondary procedure code has been allocated to an incorrect three character.

SP4 SECONDARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL

The secondary procedure code has been allocated to an incorrect fourth character.

SPIS SECONDARY PROCEDURE INCORRECTLY SEQUENCED

The Organisation has not sequenced the procedure coding according to the rules and

conventions of the classification.


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SPO SECONDARY PROCEDURE OMITTED

The secondary procedure recorded by the auditor as relevant but is missing from the

Organisation’s recorded episode.

SPNR SECONDARY PROCEDURE NOT RELEVANT

The secondary procedure recorded by the coder is not relevant to the episode of care.

Non-Coder Error

SPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF

CODING









SPD SECONDARY PROCEDURE DOCUMENTATION ISSUE



For example:


documentation and it is not clear which is correct.


SPM SECONDARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION


national standards.

For example:



SPC SECONDARY PROCEDURE CODED TO CONSULTANT SPECIFICATION





SPSC SECONDARY PROCEDURE INCORRECT DUE TO SYSTEM CONSTRAINT

Due to the system that the Organisation uses the secondary procedure code is technically



2013/14


A p p e n d i x | E.1

Appendix F: Assurance Definitions and Risk Classifications

Level of

Assurance Description

High

Our work found some low impact control weaknesses which, if addressed would improve

overall control. However, these weaknesses do not affect key controls and are unlikely to

impair the achievement of the objectives of the system. Therefore we can conclude that the

key controls have been adequately designed and are operating effectively to deliver the

objectives of the system, function or process.

Significant There are some weaknesses in the design and/or operation of controls which could impair

the achievement of the objectives of the system, function or process. However, either their

impact would be minimal or they would be unlikely to occur.

Limited There are weaknesses in the design and / or operation of controls which could have a

significant impact on the achievement of the key system, function or process objectives but

should not have a significant impact on the achievement of organisational objectives.

No There are weaknesses in the design and/or operation of controls which [in aggregate] have

a significant impact on the achievement of key system, function or process objectives and

may put at risk the achievement of organisational objectives.

Risk Rating Assessment Rationale

Critical Control weakness that could have a significant impact upon, not only the system, function

or process objectives but also the achievement of the organisation’s objectives in relation

to:

the efficient and effective use of resources.

the safeguarding of assets.

the preparation of reliable financial and operational information.

compliance with laws and regulations.

High Control weakness that has or is likely to have a significant impact upon the achievement of

key system, function or process objectives.

This weakness, whilst high impact for the system, function or process does not have a

significant impact on the achievement of the overall organisation objectives.

Medium Control weakness that:

has a low impact on the achievement of the key system, function or process

objectives;

has exposed the system, function or process to a key risk, however the likelihood

of this risk occurring is low.

Low Control weakness that does not impact upon the achievement of key system, function or

process objectives; however implementation of the recommendation would improve overall

control.


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A p p e n d i x | F.1

Appendix G: Report Data

Distribution

Name Title Distribution

A Tracey Interim Associate Director of Informatics PDF

D Croft Interim Head of Information PDF

K O'Doherty Clinical Coding Service Manager PDF

Draft issued to/responses received from

Name Title Date

K O'Doherty Clinical Coding Audit Assignment Report 2013/14 19.02.14


2013/14


A p p e n d i x | F.2

Review prepared on behalf of MIAA by

Name: Gary Bagley (ACC)

Title: Clinical Coding Academy Manager

Telephone: 0151 285 4522

Email: [email protected]

Name: Katherine Harrison (ACC)

Title: Senior Clinical Coder/ Approved Clinical Coding Auditor

Telephone: 01267 227093


Name: Tony Cobain

Title: Head of IM&T Assurance

Telephone: 0151 285 4510


Acknowledgement and further information

MIAA would like to thank all staff for their co-operation and assistance in completing this

review.

This report has been prepared as commissioned by the organisation, and is for your sole use.

If you have any queries regarding this review please contact Gary Bagley.

mailto:[email protected]



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