Basic coding from clinical records for DRGs

1. Basic coding from clinical records for DRGs Linda Best 11.45 - 12.30 Tuesday, 6th December 2011

2. Introduction Codes for diseases and procedures are the basic ingredients of the casemix recipe. Coding function was not invented for casemix.

3. Introduction cont. • The introduction of casemix funding systems requires disciplined attention to the reliability and validity of coded health data. • The connection between the codes and the health dollar ==> spotlight on coding

4. What is clinical coding? • Translation of narrative text • Understanding of clinical information • Understanding of classification system • Ability to allocate appropriate code(s)

5. Good clinical coder • Knowledge of: • Medical terminology • Medical science • Disease processes • Investigations, treatments and interventions • Content and structure of clinical record • Understanding of classification system • Understanding of coding rules and standards

6. Why code? • Provision of database of coded information • Used for: • Clinical management • Clinical research • Identifying disease trends • Monitoring quality of care

7. Why code? cont. • Used for (cont): • Funding & financial management • Review resource consumption • Workforce & facilities planning • Setting benchmarks • Comparisons

8. Accurate coding • Need for accurate coding: • Ensures information is reliable to use • Necessary for accurate DRG allocation

9. Abstraction of information from the clinical record ↓ ↓ Assignment of ICD-10-AM/ACHI codes Assignment of DRG

10. Coding process – Abstraction of information • Be aware of potential documentation issues • Unclear • Incomplete • Missing • Conflicting

11. Coding process –Abstraction of information cont. • Review the whole clinical record • Look at • Discharge information forms • Progress notes • Investigation results • Operation reports • Specialist notes

12. Coding process –Abstraction of information cont. • Apply medical terminology and medical science knowledge • Apply coding rules • Apply coding standards If you cannot analyse and abstract you cannot code

13. Coding process –Abstraction of information cont. • Methodology (used in Australian) • Read the front sheet • Read the discharge summary/letter • Compare Dx on front sheet & Discharge summary • Read history and physical examination • Identify any interventions to be coded • Review entire record

14. Example Patient presented with rapid onset of dyspnoea and chest pain. A chest X-ray revealed a spontaneous pneumothorax.

15. Coding process –Abstraction of information cont. • ACS 0010 General abstraction guidelines • Guidelines • Potential abstraction issues • Abstracting from specific areas • Examples

16. Coding process – Allocating codes • Methodology • Identify the statement to be coded & refer to the appropriate Alphabetic index • Locate the lead term • Follow any notes under the lead term • Read all nonessential and essential modifiers

17. Coding process – Allocating codes cont. • Methodology (cont) • Follow any cross-references • Refer to the Tabular list to verify code • Read and follow any coding notes • Check ACS ▼ • Assign the code

18. Coding process –Coding standards (ACS) • Principal Diagnosis selection • Essential for accurate coding • ACS 0001 Principal diagnosis • Definition “The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient, an episode of residential care or an attendance at the health care establishment, as represented by a code”

19. Coding process –Coding standards (ACS) cont. • Additional Diagnosis selection • Essential for accurate coding • ACS 0002 Additional diagnoses • Definition “A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted care, episode of residential care or attendance at a health care establishment, as represented by a code”

20. Coding process –Coding standards (ACS) cont. • Procedure selection • ACS 0016 General procedure guidelines • Definition “.. as a clinical intervention represented by a code that: • is surgical in nature; and/or • carries a procedural risk; and/or • carries an anaesthetic risk; and/or • requires specialised training; and/or • requires special facilities or equipment only available in an acute care setting

21. Coding process –Coding standards (ACS) cont. • Principal Procedure selection • ACS 0016 General procedure guidelines • Sequencing • procedure performed for treatment of the principal diagnosis • procedure performed for treatment of an additional diagnosis • diagnostic/exploratory procedure related to the principal diagnosis • diagnostic/exploratory procedure related to an additional diagnosis for the episode of care.

22. Coding process –Coding standards (ACS) cont. • Procedure selection (cont) • ACS 0042 Procedures normally not coded • List of what NOT to code

23. Accurate inpatient coding • Correct identification of Dx and Px • Assignment of correct ICD-10-AM/ACHI code • Correct sequence of Pdx

24. Causes of errors • Failure to review the entire clinical record • Failure to abstract the relevant information • Coding not validated by content of record • Selection of the incorrect ICD-10-AM codes • Sequencing errors • Transposition errors • Poor documentation