Clinical Coding – The Clinicians’ role This presentation has been produced by the NHS Classifications Service at NHS Connecting for Health. It is intended that this presentation form the bases for the key messages that need to be given to the junior members of consultants’ teams in their induction day to ensure that they are aware of the need for accurate clinically coded data. This presentation is designed to last for approximately 7-10 minutes Tutors notes and guidance have been supplied with this presentation. Comments would be welcomed for future revisions. NHS Classifications Service NHS Connecting for Health 2 nd Floor Princes Exchange Princes Square, Leeds, LS1 4HY Version 1.0

Clinical Coding The Clinicians’ Role Clinical Coding Department

What is Clinical Coding? ‘… 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. (NHS Information Authority, Clinical Coding Instruction Manual)

Main Classifications ICD-10 International Used to capture diagnostic clinical data OPCS-4 UK specific Used to capture surgical interventions & procedures

Weekly Bills of Mortality LONDON week ending 31st January 1634 The Diseases and Casualties this week Overlaid2 Quinsie1 Rickets8 Rising of the lights8 Scowering1 Scurvey2 Stillborn9 Stone1 Stopping of the stomach3 Suddenly6 Teeth16 Winde3 Worms1 Males 107 ChristenedFemale109 In all216 Males213 BuriedFemales196 In all 409 Plague0 Decreased in the buriels this week - 63 Parishes clear of the plague Parishes infected - 20 Abortive2 Aged36 Bedridden1 Bloody flux1 Bruised1 Cancer1 Chilbed3 Chrisoms19 Consumption77 Convulsions44 Cough2 Dropsie1 Executed33 Feaver10 Flox and smallpox5 Found dead in the street (an infant)1 French pox1 Gripping in the guts 13 Jaundies1 Infants18 Killed with a fall3 Murthered 1 The assize of bread set forth by order of the Lord Mayor and Court of Aldermen A penny wheaten loaf to contain eleven ounces and a half and three halfpenny white loaves the like weight

Accuracy is reliant upon… The Clinician providing the information on the patient’s diagnoses and treatment The Clinical Coder translating that information into the appropriate coded format to reflect the patient’s hospital stay

Complete diagnostic and procedural information is vital. Hepatitis K75.9 Inflammatory liver disease, unspecified Acute Hepatitis K72.0 Acute and subacute hepatic failure Alcoholic Hepatitis K70.1 Alcoholic Hepatitis Accurate and Complete Information

Possible and ? Diagnoses Chest Pain ?MI Abdominal pain - possibly cholecystitis, possibly appendicitis Chest pain investigations confirmed MI Abdominal pain treated as appendicitis

Clinicians and Data Quality The source documentation should: Be accurate and complete Reflect the patient’s episode of care Avoid the use of abbreviations Be clear and detailed Recording is legible and in indelible ink

Uses of Clinical Coded Data Clinical Statistical Clinical audit Outcome measurement Treatment effectiveness Cost analysis Clinical Governance Clinical Indicators Commissioning Financial flows Health trends Aetiology studies Epidemiological studies Casemix planning

Florence Nightingale 1863 "I am fain to sum up with an urgent appeal for adopting … some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life … In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison … If wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have means of ascertaining at present?" Florence Nightingale in Notes on Hospitals, London: Longman, Green, Roberts,Longman, and Green, 1863.

Important messages The information that you write on the source documentation must: Be complete and accurate Reflect the patient’s episode of care Avoid the use of abbreviations Be clear and detailed Recording is legible and in indelible ink Anything that is unclear about a patient’s stay the Clinical Coding Department will clarify with the appropriate member of the consultant team to ensure accuracy in the clinically coded data.