1. Clinical Coding Service Manager
Paula Wheeler, ACC
Clinical Coding Service Manager
This is a short presentation on clinical coding its importance to the Trust.

2. What is Clinical Coding?
Translation of medical terminology written by a clinician to describe a patient’s:
Complaint
Problem
Diagnosis
Clinical coding is the translation of med term written by clinician to describe a patient
complaint,
problem,
diagnosis,
treatment or
reason for seeking med attention
Put into a coded format which is nationally and internationally recognised.
Treatment
Reason for seeking medical attention
into a coded format which is nationally and internationally recognised

3. CLASSIFICATION CODING
The classifications used by this Trust for clinical coding are:
ICD10 International Classification
Used to capture diagnostic clinical data
OPCS4 a UK specific classification
Used to capture surgical interventions and procedures
Classifications used are
ICD10 – diagnostic data, international
OPCS4 – surgical interventions and procedure, UK, currently version 4.7

4. Clinical Statistical Clinical Treatment Outcome measurement Governance
Why do we code?
Treatment
effectiveness
Outcome
measurement
Clinical
Governance
Cost analysis
Clinical audit
Clinical
Statistical
Benchmarking
Health trends
Commissioning
Clinical coding has a multitude of uses from statistical to clinical.
One of the most important uses on a Trust level is for income purposes.
PbR was introduced in April 2005 to aide fair reimbursement for activity that is carried out.
Epidemiology
Aetiology
Financial flows
HRGs & PbR
Information
Governance
Clinical
Indicators
Casemix planning

5. 3 Languages of Health Terming Coding Grouping 3 languages of health
Terming – written text by drs etc ,100,000 terms
Coding – translation for text into clinical codes ,10,000 codes
Grouping – health care resource group, 100’s, current HRG4
Each HRG has a tariff which determines level of come for episodes of care

6. SOURCE DOCUMENTATION The coding source documentation should be:
Accurate and complete
Avoid use of abbreviations
Clear and detailed
Legible and in indelible ink or typed
Reflect the patients episode of care
The source documentation for clinical coding should be
Accurate and complete,
avoid use of abbreviations,
clear and detailed,
legible,
reflect patients episode of care

7. Co-morbidities
The hospital episode length of stay and co-morbidities can affect the HRG allocation.
Epilepsy
Diabetes
Asthma
Hypertension
Heart conditions
Recently published guidance list of all co-morbidities that must be coded when mentioned in the clinical record
Co-morbidities and complications can affect the HRG allocation so it is important these are recorded in the clinical notes, discharge summary and coded
Published list of co-morbidities that must be coded when documented
There should be a laminated copy on each ward

8. Financial impact of Incomplete terming
R00.2 (ICD10) Palpitations
HRG EB07I
Arrhythmia or conduction disorders, without CC
Tariff £617
Terming needs to be accurate and complete to support coding
Missing information can affect the HRG assignment and group a patient to a without co-morbidity/complication HRG

9. Complete terming R00.2 (ICD10) Palpitations
E11.9 (ICD10) Type 2 diabetes
HRG EB07H
Arrhythmia or conduction disorders, with CC
Tariff £1,695
Including the term for co-morbidity of type 2 diabetes in the clinical documentation changes the HRG assignment in this example, this generated additional income of £1,078

10. Terming
R04.0 (ICD10) Epistaxis E05.1 (OPCS)Cauterisation of internal nose HRG CZ12Y Minor Nose Procedures 19 years and over without CC Tariff £719
Not giving accurate details of procedures carried out can have an impact on the HRG assignment

11. Be specific R04.0 (ICD10) Epistaxis
E05.2 (OPCS) Ligation of artery of internal nose
HRG CZ15Q
Complex Major Nose Procedures without CC
Tariff £2,975
By being more specific in procedure documentation in this example an additional £2,256 income has been generated

12. BENEFIT OF RICHER CODING
Finance
Information
Research
Cancer registry
Finance – for the income of the Trust & ensuring correct reimbursement for activity
Information – business planning etc
Research
Cancer registry – all our cancer coding is sent to cancer registry
Everyone benefits

13. Clinical Coding Contacts
Paula Wheeler , Clinical Coding Service Manager Jo Counter, Clinical Coding Training Manager Ann Buttle, Clinical Coding Data Analyst & Auditor Margaret Caldaralo, Team Leader Daniel Whittaker, Team Leader Richard Gale, Clinical Coding Auditor
Contact details for key clinical coding personnel

14. Thank You
Any Questions?