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

2. 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

3. NHS Classifications Service
Developing classifications
Incl ICD-10 & OPCS-4
HRG
Cross
-maps
NHS Classifications
standards
guidance & advice
SNOMED-CT
Audit Methodology
SUS
Professional
Accreditation and training
DH initiatives
Care Record
Info Governance

4. 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

5. 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

6. 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

7. 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

8. 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

9. Where to start? Explore what audit results mean for Trusts
Identify how this will inform a data quality programme

10. 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

11. 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

12. What you can do about it ? Support coder education and training
Address documentation issues
Engage clinicians ….. their patients…. their data

13. Useful Contacts
For clinical coding queries, classification training products, course bookings and enquiries contact:
For OPCS requests for change