a snapshot analysis of general surgical coding at nmh
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A snapshot analysis of General Surgical coding at NMH. Presentation at Surgical Department meeting 22/3/13 Audit by FY1s Dhakshi Muhundhakumar Sapna Aggarwal. Why is coding important?. Summarises the activity of teams and departments

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a snapshot analysis of general surgical coding at nmh

A snapshot analysis ofGeneral Surgical coding at NMH

Presentation at Surgical Department meeting 22/3/13

Audit by FY1s

Dhakshi Muhundhakumar

Sapna Aggarwal

why is coding important
Why is coding important?
  • Summarises the activity of teams and departments
  • This information is key to the reporting structure which enables Payment by Results for the trust
  • In the private sector the process is much more incentivised
  • Can also affect service planning and delivery decisions
  • It is down to individual trusts and departments to ensure the accuracy of their coding and therefore their income!
how is information gathered
Informatics:

Coders (non-clinical) gather information from op notes and discharge summaries

NHS classifications used to record diseases and procedures (ICD-10 and OPCS-4)

Morbidity and mortality data:

Juniors gather information from op lists, patient lists etc.

How is information gathered?
an ongoing process
An ongoing process
  • Initial retrospective study in December
  • Prospective study for January 2013

Operating codes put up in theatres (Early February)

  • Prospective study February 2013 and March 2013
  • So…has there been any improvement?
prospective data january 2013
Prospective data – January 2013
  • Elective procedures for each of the General surgical consultants
  • Comparing data collected by F1s versus data output from informatics (collected by coders)
early february 2013
Early February 2013
  • Codes put up in operating theatres
  • Similar prospective analysis once more…
march 2013 so far
March 2013 so far…
  • Presence of codes in theatres established
  • Data gathered for Upper GI team
what have we found
What have we found?
  • There are definite quantitative and qualitative discrepancies in the data from informatics vs patient lists.
  • These discrepancies are costing the trust money.
  • The accuracy of coding has been shown to improve in Feb 2013 then March 2013, with simple measures such as giving surgeons access to codes.
how can we improve things further
How can we improve things further?
  • Registrars can put codes on notes within seconds. This can be encouraged by:
    • Codes in quiet room
    • More defined codes for colorectal
  • Discharge summary aspect
  • Session with coders
  • ? Block transfer from recovery
  • ? Incentive for departments / recognition by management
any questions
Any questions?
  • Thank you for listening!
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