Clinical Coding: accurate, timely, quality data – does it matter?

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. Developing classifications Incl ICD-10 & OPCS-4 HRG NHS Classifications Service Cross -maps NHS Classifications standards guidance & advice SNOMED-CT AuditMethodology SUS Professional Accreditation and training DHinitiatives 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: www.cfh.nhs.uk/clinicalcoding datastandards@nhs.net For OPCS requests for change www.cfh.nhs.uk/opcsrequestsportal