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Payment by Results: Clinical Coding Issues. Janet Kempson Data Quality & Clinical Coding Manager Cheshire & Merseyside. Outline. Terming, Classifying, Grouping The Coding Process HRGs Coding examples Coding issues. THE PATIENT.

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payment by results clinical coding issues
Payment by Results:Clinical Coding Issues

Janet Kempson

Data Quality & Clinical Coding Manager

Cheshire & Merseyside

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

outline
Outline
  • Terming, Classifying, Grouping
  • The Coding Process
  • HRGs
  • Coding examples
  • Coding issues

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

the patient
THE PATIENT

NCRS NSFs Decision support SNOMED CT Care pathways CLINICAL TERMS TERMING Clinical Clinical audit READ Research

Summarising

CDS NationalInternational ICD-10 OPCS-4/NCoI CLASSIFYINGStatistics

Costing GROUPS GROUPINGCommissioningPayment by Results

Needs assessment HRGsClinical Audit Other groupsHealth care research

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

statistical classifications
Statistical Classifications

“…a system of categories to which morbid entities are assigned according to established criteria” ICD10 Vol 2 Ch 2

“Every disease or morbid condition must have a definite and appropriate place as an inclusion in one of the categories of the statistical classification” ICD 9 Vol 1 page vii.

Statistical classifications have rules (i.e. The Coding Frame) to ensure uniformity, which is essential if the information is to be of use.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

the patient5
THE PATIENT

NCRS NSFs Decision support SNOMED CT Care pathways CLINICAL TERMS TERMING Clinical Clinical audit READ Research

Summarising

CDS NationalInternational ICD-10 OPCS-4/NCoI CLASSIFYINGStatistics

Costing GROUPS GROUPINGCommissioningPayment by Results

Needs assessment HRGsClinical Audit Other groupsHealth care research

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

the coding process
The Coding Process
  • The coding process is the translation of medical terminology into codes of the statistical classifications.
  • Medical terminology describing the reason for a patient’s encounter appears on a source document e.g. case notes, discharge letters, clinical work-sheets, discharge proformas.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

the coder s role
The Coder’s Role
  • The coder’s role is to extract the relevant information from the case note and to assign codes which represent a complete picture of the patient’s current care.
  • All codes assigned must represent an accurate translation of the diagnostic statements or terminology used by the clinician

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

general rules for coding
General Rules for Coding
  • Code every problem which affects the care, or influences the health status or is the reason for the hospital stay on the episode being coded.
  • Code the minimum number of codes which accurately reflect the patient’s care on the encounter.
  • Code each problem to the furthest level of specificity available in the classification.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

definition of primary diagnosis hes who
Definition of Primary Diagnosis (HES & WHO)
  • The first field(s) of the coded clinical record will contain the main condition treated or investigated during the relevant episodes of healthcare.
  • Where there is no definitive diagnosis, the main symptom, abnormal findings, or problem should be selected as the main condition.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

healthcare resource groups
Healthcare Resource Groups
  • Each group contains a set of treatments that are clinically similar and that use roughly the same level of resources.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

hrg chapters
HRG Chapters

A – Nervous SystemB – Eyes & PeriorbitaC – Mouth, Head, Neck & EarsD – Respiratory SystemE – Cardiac Surgery & Primary Cardiac ConditionsF – Digestive SystemG – Hepato – biliary & Pancreatic SystemH – Musculoskeletal SystemJ – Skin, Breast & BurnsK – Endocrine & Metabolic System

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

hrg chapters continued
HRG Chapters (continued)

L – Urinary Tract & Male Reproductive SystemM – Female Reproductive SystemN – Obstetrics & Neonatal CareP – Diseases of ChildhoodQ – Vascular SystemR – Spinal Surgery & Primary Spinal ConditionsS – Haematology, Infectious Diseases, Poisoning and Non- Specific GroupingsT – Mental HealthU – Undefined Groups

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

admitted patient care data items
Admitted Patient Care Data Items
  • Primary and secondary procedures
  • Primary and secondary diagnoses
  • Age
  • Sex
  • Method of Discharge
  • Legal Status
  • Length of Stay

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

version 3 algorithm part one
Version 3 Algorithm - Part One

ValidPDx

U01 Primary Diagnosis(PDx) Invalid

No

Yes

ProcedureRecorded

Group UsingDiagnosis (Dx)

No

Yes

AnyProcedureValid

No

U02 PrimaryProcedure Invalid

Yes

Select Highest Hierarchical Procedure

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

version 3 algorithm part one continued
Version 3 Algorithm - Part One (continued)

AnySignificantProcedure

Group UsingDiagnosis (Dx)

No

MinorProcedure &LOS> 1 Day

Group UsingDiagnosis (Dx)

Yes

No

Group UsingSelected Procedure

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

version 3 algorithm part two
Version 3 Algorithm - Part Two

Group UsingDiagnosis (Dx)

Select Primary Diagnosisor Secondary Diagnosis if Dagger and Asterix Code

Any Dxof Holiday ReliefCare

Yes

S24 Holiday Relief Care

Any Dxor Px of Chemo-therapy

Yes

Chemotherapy Group(C98, D98 etc.)

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

version 3 algorithm part two continued
Version 3 Algorithm - Part Two (continued)

TwoMajor Dxs andAge> 69

Yes

Complex Elderly Group(A99, C99 etc.)

Any Dxof Planned Procedurenot carried out

Yes

S22 Planned Procedurenot carried out

Group UsingSelected Diagnosis

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

undefined groups
Undefined Groups
  • U01 Invalid Primary Diagnosis
  • U02 Invalid Dominant Procedure
  • U04 Age Outside Range 0-130
  • U05 Age Conflicting with Diagnosis or Procedure
  • U07 Poorly Coded Primary Diagnosis
  • U08 Poorly Coded Dominant Procedure
  • U09 Invalid Length of Stay

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

chapter j skin breast burns surgical groups v3
Chapter J: Skin, Breast & Burns Surgical Groups – V3

ProcedureGroups

Complex BreastRecon Using Flaps

J01

Maj Breast SurgeryInclude Plastic PX

Age>49 orwith cc?

Yes

J02

No

J03

Age>49 orwith cc?

Yes

Intermediate BreastSurgery

J04

No

J05

Age>69 orwith cc?

Yes

Minor BreastSurgery

J06

No

J07

Lymph DissectionProcedures

J11

Soft TissueProcedures

J12

1

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

example of incomplete coding 1
Example of incomplete coding 1

Incomplete coding:

D05.1 (ICD10) Intraductal carcinoma in situ

B28.3 (OPCS) Excision of lesion of breast (lumpectomy)

HRG J05 Costs = £853

Correct Coding:

D05.1 (ICD10) Intraductal carcinoma in situ

I10 (ICD10) Hypertension

B28.3 (OPCS) Excision of lesion of breast (lumpectomy)

HRG J04 Costs = £1094

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

example of incomplete coding 2
Example of incomplete coding 2

Incomplete coding:

I21.1 (ICD10) Acute transmural myocardial infarction of inferior wall

I44.1 (ICD10) Atrioventricular block, second degree

HRG E12 Costs = £2037

Correct Coding:

I21.1 (ICD10) Acute transmural myocardial infarction of inferior wall

I44.1 (ICD10) Atrioventricular block, second degree

K60.1 (OPCS) Implantation of intravenous cardiac pacemaker

Y70.5 (OPCS) Temporary operations

HRG E07 Costs = £4659

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

example of incomplete coding 3
Example of incomplete coding 3

Incomplete coding:

C18.7 (ICD10) Cancer sigmoid colon

H10.9 (OPCS) Excision of sigmoid colon NOS

HRG F32 Costs = £4812

Complete coding:

C18.7 (ICD10) Cancer sigmoid colon

H10.5 (OPCS) Excision of sigmoid colon + colostomy

H15.2 (OPCS) End colostomy

HRG F31 Costs = £5604

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

example of incomplete coding 4
Example of incomplete coding 4

Incomplete coding:

C75.1 (OPCS) Insertion of prosthetic replacement of lens

C74.9 (OPCS) Unspecified extraction of lens

HRG B14 Costs = £847

Complete coding:

C75.1 (OPCS) Insertion of prosthetic replacement for lens

C71.2 (OPCS) Phakoemulsification of lens

HRG B13 Costs = £715

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

example of incomplete coding 5
Example of incomplete coding 5

Incomplete coding: (aged 68 years)

S46.9 (ICD10) Injury of unspec muscle & tendon at shoulder & upper arm level

X50.0 (ICD10) Overexertion & strenuous or repetitive movements

T67.9 (OPCS) Primary repair of tendon unspecified

Z54.5 (OPCS) Muscle of upper arm (triceps brachii)

Z94.2 (OPCS) Right sided operation

HRG H19 Costs = £1435

Complete coding: (aged 68 years)

S46.9 (ICD10) Injury of unspec muscle & tendon at shoulder & upper arm level

X50.0 (ICD10) Overexertion & strenuous or repetitive movements

Z60.2 (ICD10) Living alone

T67.9 (OPCS) Primary repair of tendon unspecified

Z54.5 (OPCS) Muscle of upper arm (triceps brachii)

Z94.2 (OPCS) Right sided operation

HRG H18 Costs = £4262

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

the financial impact
The Financial Impact

Trust income could be at risk if:

  • 100% of episodes are not coded within the required timescales
  • there are any HRG “U” codes
  • there are missing CCs
  • there are any coding errors

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

ig toolkit requirement 7302
IG Toolkit - Requirement 7302
  • Has the Trust had an external audit of clinical coding based on national standards within the last 12 months?
  • The Trust has evidence that there are established procedures for the regular assessment of clinical coding. The results of an external clinical coding audit based on the requirements and standards within the ‘Data Quality Audit Framework for Coded Clinical Data’ and undertaken by external staff registered on the approved list of clinical coding auditors within the last twelve months are noted and actioned.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

igt clinical coding audit
IGT – Clinical Coding Audit

Level 1

- established procedures for regular internal audit

- at least one audit by external staff in the last 12 months.

Level 2

- established procedures for regular internal audit

- an external audit in last 12 mths based on requirements and standards of the national framework, undertaken by staff registered on the national approved list of clinical coding auditors.

Level 3

- as Level 2 plus % accuracy scores should be > or = toDiagnosis: Primary - 90% Secondary - 80%

Procedure: Primary - 90% Secondary - 80%

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

coding issues incompleteness inaccuracies
Coding Issues – Incompleteness/Inaccuracies
  • Use of discharge summaries as the main source document – missing CCs
  • State of casenotes
  • Patient transfers
  • Training – coders must keep up-to-date
  • Insufficient internal audit
  • Insufficient involvement of clinicians

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

coding issues timeliness
Coding Issues - Timeliness
  • End of quarter/end of year catch up is not good enough for PBR
  • Must now meet ‘Flex’ and ‘Freeze’ dates
  • Issues affecting timeliness include:
  • - Source documentation
  • - Coding resources
  • - Training period (12 - 18 months)
  • - Recruitment and retention of staff

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

source documentation
Source Documentation
  • Case notes to coders – need clerical support
  • Coders to case notes - problems working on wards
  • Proformas vs. case notes
  • Speed vs. depth of coding
  • Review final discharge letter for full accurate coding
  • But this means coding twice which impacts on resources

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

coding resources
Coding Resources
  • 7,500 FCEs per WTE coder p.a. (additional requirement for OPD
  • Supervisor must be additional (role includes checking work of trainees, regular internal audits, training & development of all coders)
  • 12-18 month training period for new coders
  • Update training for experienced coders
  • Departmental structure

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

coders training programme
Coders’ Training Programme
  • Year 1
    • Foundation Course with 6 and 12 month reviews
  • Year 2
    • Anatomy & Physiology workshop
    • Specialty workshops
  • Year 3
    • Refresher course
    • Preparation for Qualification

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

recruitment and retention of coders
Recruitment and Retention of Coders
  • Appropriate grading structure
  • Agenda for Change
  • Appropriate selection criteria for new entrants
  • Opportunities for trained coders in primary care, information management, clinical audit, etc.
  • Acute trusts are the ‘training ground’
  • Coders are worried about the future.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

the future
The Future
  • NCoI – impact of training & implementation period, need to recruit extra resources now
  • NHS Care Records Service
  • SNOMED CT
  • Templates, pick lists, cross mappings, etc.
  • The role of the coder will change over the next 10 years.
  • Coders will need to be supported with ETD and good leadership during the changes

or PBR could be at risk

Data Quality & Clinical Coding Team (Cheshire & Merseyside)

final thought
Final Thought

Correct and complete Clinical Coding relies on both the skills of well trained coders and the provision of accurate information recorded in clinical records…..

BUT - this is a trust wide responsibility, not just the coders.

Data Quality & Clinical Coding Team (Cheshire & Merseyside)