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Clinical Coding: accurate, timely, quality data – does it matter?. Christine Noonan Principal Clinical Classifications Advisor NHS Classifications Service NHS Connecting For Health March 2009. Coding MATTERS – Coding COUNTS. Accurate data for quality information

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clinical coding accurate timely quality data does it matter

Clinical Coding: accurate, timely, quality data – does it matter?

Christine Noonan

Principal Clinical Classifications Advisor

NHS Classifications Service

NHS Connecting For Health

March 2009

coding matters coding counts

Coding MATTERS – Coding COUNTS

Accurate data for quality information

Key to quality information is adherence to standards, training and audit guided by the national resource for clinical coding standards

The NHS Classification Service is the definitive source of coding guidance and determines the clinical classification national standards in the NHS

nhs classifications service

Developing classifications

Incl ICD-10 & OPCS-4

HRG

NHS Classifications Service

Cross

-maps

NHS Classifications

standards

guidance & advice

SNOMED-CT

AuditMethodology

SUS

Professional

Accreditation and training

DHinitiatives

Care Record

Info Governance

working to support the nhs

Working to support the NHS

Strengthening NHS Clinical Coding Standards

Developing and maintaining standard coding audit methodology

Updating OPCS-4 classification

Training programmes

Information Governance

opcs 4 5 mandated for use on 01 april 09

OPCS-4.5 mandated for use on 01-April-09

Summary of Changes:

-1.88% increase in number of codes from OPCS-4.4

- new entries fall within existing chapters.

- no change to the architecture of the clinical classification

- most changes are seen in Trauma & Orthopaedics

- new codes for spinal decompressions, fusions and interventional radiology procedures

training courses currently available

Training Courses currently available

-Chemo/Radiotherapy Workshop

- Anatomy & Oncology Workshop

- Clinical Coding Audit Workshop

- Clinical Coding Foundation Course

- Clinical Coding Refresher Course

- NCCQ Revision Workshop

- Train the Trainer Programme

- Trainer Refresher

- Bespoke Training including PCT Awareness

audit commission findings

Audit Commission findings

Main issues identified as cause of clinical coding errors:

Quality of documentation

Coding arrangements

Co-morbidity recording

Lack of clinician involvement

Training issues

audit commission findings best practice
Audit Commission Findings Best Practice
  • Documentation clearly highlighting coding requirement for the episode
  • Close working relationships with ward staff and medical records
  • Clinician involvement
  • Coding arrangements
where to start

Where to start?

Explore what audit results mean for Trusts

Identify how this will inform a data quality programme

so what are nhs cfh doing about it

So what are NHS CFH doing about it?

Working in partnership with DH and IC

Continued working in partnership with the Audit Commission

Developing an outline for a National Data Quality programme

what you can do about it

What you can do about it ?

Use our national helpdesk for queries as the definitive source of guidance

Ensure organisational commitment

Maintain data quality through

continuous coding audit

what you can do about it1

What you can do about it ?

Support coder education and training

Address documentation issues

Engage clinicians ….. their patients…. their data

useful contacts

Useful Contacts

For clinical coding queries, classification training products, course bookings and enquiries contact:

www.cfh.nhs.uk/clinicalcoding

datastandards@nhs.net

For OPCS requests for change

www.cfh.nhs.uk/opcsrequestsportal