Improve accuracy of clinical coding Advice for clinicians

About me James Ransom Deputy Clinical Coding Team Leader Been an Accredited Clinical Coder since 2011 Been in at Ipswich Hospital since 2002.

What is clinical coding? Written information that describes a patient’s complaint, problem, diagnosis, treatment or other reason for seeking medical attention is translated into an alphanumerical coded format. ICD-10 – Diseases and related health problems OPCS-4 – Procedures and interventions Clinical coders use their skills, knowledge, and experience to assign codes accurately and consistently in accordance with national clinical coding standards. The codes can be easily tabulated, aggregated and sorted for statistical analysis. All individual codes assigned during an episode are grouped to generate an HRG code- this is used to reimburse hospital activity by Payment by Results (PbR).

What can you do to improve accuracy of coding? Clearly record details of all diagnosis (including comorbidities) and procedures (including those carried out on the ward) in the notes. Write the main diagnosis first. For injuries- note the cause. For overdoses – note each drug, specify which drug is the most significant overdose. For infections – note the organism. If the organism is resistant to an antibiotic, record this. For post op complications – note the nature of the complication. For cancelled operations – note the reason for cancellation.

What can you do to improve accuracy of coding? If a clear diagnosis has not been reached, make sure you detail the main symptoms in the notes or discharge summary. Any ‘query’, ‘possible’ or ‘likely’ diagnosis, or a diagnosis proceeded by a ‘?’ cannot be coded. If a histology result is needed for a definitive diagnosis, note this down

What can you do to improve accuracy of coding? Avoid the use of new or ambiguous abbreviations e.g. MS= Multiple sclerosis or mitral stenosis Clinical coders are not permitted to make any clinical inferences.

What can you do to improve accuracy of coding? All relevant co-morbidities MUST be recorded for each current spell, reference cannot be made to previous spells.

What can you do to improve accuracy of coding? If a pathway is provided for admissions or discharge – USE IT.

What can you do to improve accuracy of coding? Details of all diagnosis, co-morbidities and procedures MUST be recorded on the evolve discharge summary.

What can you do to improve accuracy of coding? If image control or minimal access approach is used for a procedure, it should be clearly stated.

What can you do to improve accuracy of coding? When recording procedures it is IMPERATIVE that the actual operation is recorded and not the intended operation.

What can you do to improve accuracy of coding? The source document should: Be accurate and complete; Reflect the patients episode of care; Avoid the use of abbreviations; Be clear and detailed; Have handwriting that is legible and in indelible ink.

Can code Diagnosis- Probable- Treat as- Presumed-

Unable to code Query- Likely- Possible- ?

Thank you for reading. Any questions please don’t hesitate to contact coding on ex 6335 Or email clinical.coding@ipswichhospital.nhs.uk