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A snapshot analysis of General Surgical coding at NMH

A snapshot analysis of General Surgical coding at NMH. Presentation at Surgical Department meeting 22/3/13 Audit by FY1s Dhakshi Muhundhakumar Sapna Aggarwal. Why is coding important?. Summarises the activity of teams and departments

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A snapshot analysis of General Surgical coding at NMH

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  1. A snapshot analysis ofGeneral Surgical coding at NMH Presentation at Surgical Department meeting 22/3/13 Audit by FY1s Dhakshi Muhundhakumar Sapna Aggarwal

  2. Why is coding important? • Summarises the activity of teams and departments • This information is key to the reporting structure which enables Payment by Results for the trust • In the private sector the process is much more incentivised • Can also affect service planning and delivery decisions • It is down to individual trusts and departments to ensure the accuracy of their coding and therefore their income!

  3. Informatics: Coders (non-clinical) gather information from op notes and discharge summaries NHS classifications used to record diseases and procedures (ICD-10 and OPCS-4) Morbidity and mortality data: Juniors gather information from op lists, patient lists etc. How is information gathered?

  4. An ongoing process • Initial retrospective study in December • Prospective study for January 2013 Operating codes put up in theatres (Early February) • Prospective study February 2013 and March 2013 • So…has there been any improvement?

  5. Prospective data – January 2013 • Elective procedures for each of the General surgical consultants • Comparing data collected by F1s versus data output from informatics (collected by coders)

  6. Mr Stoker elective procedures Jan 2013 I : PL 86%

  7. Mr Al Mukhtar Elective procedures Jan 2013 I : PL 67%

  8. Miss Davis elective procedures Jan 2013 I : PL 75%

  9. Miss Myint elective procedures Jan 2013 I : PL 38%

  10. Mr Dvorkin elective procedures Jan 2013 I : PL 75%

  11. Mr Navaratnam elective procedures Jan 2013 I : PL 66%

  12. I : PL 59% Mr Fafemi elective procedures Jan 2013

  13. Mr Behrenwala elective procedures Jan 2013 I : PL 85%

  14. Early February 2013 • Codes put up in operating theatres • Similar prospective analysis once more…

  15. Mr Stoker elective procedures Feb 2013 I : PL 89%

  16. Mr Al-Mukhtar elective procedures Feb 2013 I : PL 75%

  17. Miss Davis elective procedures Feb 2013 I : PL 133%

  18. Miss Myint elective procedures Feb 2013 I : PL 100%

  19. Mr Dvorkin elective procedures Feb 2013 I : PL 100%

  20. Mr Navaratnam elective procedures Feb 2013 I : PL 100%

  21. Mr Fafemi elective procedures Feb 2013 I : PL 45%

  22. Mr Behrenwala elective procedures Feb 2013 I : PL 35%

  23. March 2013 so far… • Presence of codes in theatres established • Data gathered for Upper GI team

  24. Mr Stoker elective procedures March 2013 I : PL 75%

  25. Mr Al-Mukhtar elective procedures March 2013 I : PL 89%

  26. What have we found? • There are definite quantitative and qualitative discrepancies in the data from informatics vs patient lists. • These discrepancies are costing the trust money. • The accuracy of coding has been shown to improve in Feb 2013 then March 2013, with simple measures such as giving surgeons access to codes.

  27. How can we improve things further? • Registrars can put codes on notes within seconds. This can be encouraged by: • Codes in quiet room • More defined codes for colorectal • Discharge summary aspect • Session with coders • ? Block transfer from recovery • ? Incentive for departments / recognition by management

  28. Any questions? • Thank you for listening!

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