Payment by Results: Clinical Coding Issues

1. Payment by Results:Clinical Coding Issues Janet Kempson Data Quality & Clinical Coding Manager Cheshire & Merseyside Data Quality & Clinical Coding Team (Cheshire & Merseyside)

2. Outline • Terming, Classifying, Grouping • The Coding Process • HRGs • Coding examples • Coding issues Data Quality & Clinical Coding Team (Cheshire & Merseyside)

3. THE PATIENT NCRS NSFs Decision support SNOMED CT Care pathways CLINICAL TERMS TERMING Clinical Clinical audit READ Research Summarising CDS NationalInternational ICD-10 OPCS-4/NCoI CLASSIFYINGStatistics Costing GROUPS GROUPINGCommissioningPayment by Results Needs assessment HRGsClinical Audit Other groupsHealth care research Data Quality & Clinical Coding Team (Cheshire & Merseyside)

4. Statistical Classifications “…a system of categories to which morbid entities are assigned according to established criteria” ICD10 Vol 2 Ch 2 “Every disease or morbid condition must have a definite and appropriate place as an inclusion in one of the categories of the statistical classification” ICD 9 Vol 1 page vii. Statistical classifications have rules (i.e. The Coding Frame) to ensure uniformity, which is essential if the information is to be of use. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

5. THE PATIENT NCRS NSFs Decision support SNOMED CT Care pathways CLINICAL TERMS TERMING Clinical Clinical audit READ Research Summarising CDS NationalInternational ICD-10 OPCS-4/NCoI CLASSIFYINGStatistics Costing GROUPS GROUPINGCommissioningPayment by Results Needs assessment HRGsClinical Audit Other groupsHealth care research Data Quality & Clinical Coding Team (Cheshire & Merseyside)

6. The Coding Process • The coding process is the translation of medical terminology into codes of the statistical classifications. • Medical terminology describing the reason for a patient’s encounter appears on a source document e.g. case notes, discharge letters, clinical work-sheets, discharge proformas. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

7. The Coder’s Role • The coder’s role is to extract the relevant information from the case note and to assign codes which represent a complete picture of the patient’s current care. • All codes assigned must represent an accurate translation of the diagnostic statements or terminology used by the clinician Data Quality & Clinical Coding Team (Cheshire & Merseyside)

8. General Rules for Coding • Code every problem which affects the care, or influences the health status or is the reason for the hospital stay on the episode being coded. • Code the minimum number of codes which accurately reflect the patient’s care on the encounter. • Code each problem to the furthest level of specificity available in the classification. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

9. Definition of Primary Diagnosis (HES & WHO) • The first field(s) of the coded clinical record will contain the main condition treated or investigated during the relevant episodes of healthcare. • Where there is no definitive diagnosis, the main symptom, abnormal findings, or problem should be selected as the main condition. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

10. Healthcare Resource Groups • Each group contains a set of treatments that are clinically similar and that use roughly the same level of resources. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

11. HRG Chapters A – Nervous SystemB – Eyes & PeriorbitaC – Mouth, Head, Neck & EarsD – Respiratory SystemE – Cardiac Surgery & Primary Cardiac ConditionsF – Digestive SystemG – Hepato – biliary & Pancreatic SystemH – Musculoskeletal SystemJ – Skin, Breast & BurnsK – Endocrine & Metabolic System Data Quality & Clinical Coding Team (Cheshire & Merseyside)

12. HRG Chapters (continued) L – Urinary Tract & Male Reproductive SystemM – Female Reproductive SystemN – Obstetrics & Neonatal CareP – Diseases of ChildhoodQ – Vascular SystemR – Spinal Surgery & Primary Spinal ConditionsS – Haematology, Infectious Diseases, Poisoning and Non- Specific GroupingsT – Mental HealthU – Undefined Groups Data Quality & Clinical Coding Team (Cheshire & Merseyside)

13. Admitted Patient Care Data Items • Primary and secondary procedures • Primary and secondary diagnoses • Age • Sex • Method of Discharge • Legal Status • Length of Stay Data Quality & Clinical Coding Team (Cheshire & Merseyside)

14. Version 3 Algorithm - Part One ValidPDx U01 Primary Diagnosis(PDx) Invalid No Yes ProcedureRecorded Group UsingDiagnosis (Dx) No Yes AnyProcedureValid No U02 PrimaryProcedure Invalid Yes Select Highest Hierarchical Procedure Data Quality & Clinical Coding Team (Cheshire & Merseyside)

15. Version 3 Algorithm - Part One (continued) AnySignificantProcedure Group UsingDiagnosis (Dx) No MinorProcedure &LOS> 1 Day Group UsingDiagnosis (Dx) Yes No Group UsingSelected Procedure Data Quality & Clinical Coding Team (Cheshire & Merseyside)

16. Version 3 Algorithm - Part Two Group UsingDiagnosis (Dx) Select Primary Diagnosisor Secondary Diagnosis if Dagger and Asterix Code Any Dxof Holiday ReliefCare Yes S24 Holiday Relief Care Any Dxor Px of Chemo-therapy Yes Chemotherapy Group(C98, D98 etc.) Data Quality & Clinical Coding Team (Cheshire & Merseyside)

17. Version 3 Algorithm - Part Two (continued) TwoMajor Dxs andAge> 69 Yes Complex Elderly Group(A99, C99 etc.) Any Dxof Planned Procedurenot carried out Yes S22 Planned Procedurenot carried out Group UsingSelected Diagnosis Data Quality & Clinical Coding Team (Cheshire & Merseyside)

18. Undefined Groups • U01 Invalid Primary Diagnosis • U02 Invalid Dominant Procedure • U04 Age Outside Range 0-130 • U05 Age Conflicting with Diagnosis or Procedure • U07 Poorly Coded Primary Diagnosis • U08 Poorly Coded Dominant Procedure • U09 Invalid Length of Stay Data Quality & Clinical Coding Team (Cheshire & Merseyside)

19. Chapter J: Skin, Breast & Burns Surgical Groups – V3 ProcedureGroups Complex BreastRecon Using Flaps J01 Maj Breast SurgeryInclude Plastic PX Age>49 orwith cc? Yes J02 No J03 Age>49 orwith cc? Yes Intermediate BreastSurgery J04 No J05 Age>69 orwith cc? Yes Minor BreastSurgery J06 No J07 Lymph DissectionProcedures J11 Soft TissueProcedures J12 1 Data Quality & Clinical Coding Team (Cheshire & Merseyside)

20. Example of incomplete coding 1 Incomplete coding: D05.1 (ICD10) Intraductal carcinoma in situ B28.3 (OPCS) Excision of lesion of breast (lumpectomy) HRG J05 Costs = £853 Correct Coding: D05.1 (ICD10) Intraductal carcinoma in situ I10 (ICD10) Hypertension B28.3 (OPCS) Excision of lesion of breast (lumpectomy) HRG J04 Costs = £1094 Data Quality & Clinical Coding Team (Cheshire & Merseyside)

21. Example of incomplete coding 2 Incomplete coding: I21.1 (ICD10) Acute transmural myocardial infarction of inferior wall I44.1 (ICD10) Atrioventricular block, second degree HRG E12 Costs = £2037 Correct Coding: I21.1 (ICD10) Acute transmural myocardial infarction of inferior wall I44.1 (ICD10) Atrioventricular block, second degree K60.1 (OPCS) Implantation of intravenous cardiac pacemaker Y70.5 (OPCS) Temporary operations HRG E07 Costs = £4659 Data Quality & Clinical Coding Team (Cheshire & Merseyside)

22. Example of incomplete coding 3 Incomplete coding: C18.7 (ICD10) Cancer sigmoid colon H10.9 (OPCS) Excision of sigmoid colon NOS HRG F32 Costs = £4812 Complete coding: C18.7 (ICD10) Cancer sigmoid colon H10.5 (OPCS) Excision of sigmoid colon + colostomy H15.2 (OPCS) End colostomy HRG F31 Costs = £5604 Data Quality & Clinical Coding Team (Cheshire & Merseyside)

23. Example of incomplete coding 4 Incomplete coding: C75.1 (OPCS) Insertion of prosthetic replacement of lens C74.9 (OPCS) Unspecified extraction of lens HRG B14 Costs = £847 Complete coding: C75.1 (OPCS) Insertion of prosthetic replacement for lens C71.2 (OPCS) Phakoemulsification of lens HRG B13 Costs = £715 Data Quality & Clinical Coding Team (Cheshire & Merseyside)

24. Example of incomplete coding 5 Incomplete coding: (aged 68 years) S46.9 (ICD10) Injury of unspec muscle & tendon at shoulder & upper arm level X50.0 (ICD10) Overexertion & strenuous or repetitive movements T67.9 (OPCS) Primary repair of tendon unspecified Z54.5 (OPCS) Muscle of upper arm (triceps brachii) Z94.2 (OPCS) Right sided operation HRG H19 Costs = £1435 Complete coding: (aged 68 years) S46.9 (ICD10) Injury of unspec muscle & tendon at shoulder & upper arm level X50.0 (ICD10) Overexertion & strenuous or repetitive movements Z60.2 (ICD10) Living alone T67.9 (OPCS) Primary repair of tendon unspecified Z54.5 (OPCS) Muscle of upper arm (triceps brachii) Z94.2 (OPCS) Right sided operation HRG H18 Costs = £4262 Data Quality & Clinical Coding Team (Cheshire & Merseyside)

25. The Financial Impact Trust income could be at risk if: • 100% of episodes are not coded within the required timescales • there are any HRG “U” codes • there are missing CCs • there are any coding errors Data Quality & Clinical Coding Team (Cheshire & Merseyside)

26. IG Toolkit - Requirement 7302 • Has the Trust had an external audit of clinical coding based on national standards within the last 12 months? • The Trust has evidence that there are established procedures for the regular assessment of clinical coding. The results of an external clinical coding audit based on the requirements and standards within the ‘Data Quality Audit Framework for Coded Clinical Data’ and undertaken by external staff registered on the approved list of clinical coding auditors within the last twelve months are noted and actioned. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

27. IGT – Clinical Coding Audit Level 1 - established procedures for regular internal audit - at least one audit by external staff in the last 12 months. Level 2 - established procedures for regular internal audit - an external audit in last 12 mths based on requirements and standards of the national framework, undertaken by staff registered on the national approved list of clinical coding auditors. Level 3 - as Level 2 plus % accuracy scores should be > or = toDiagnosis: Primary - 90% Secondary - 80% Procedure: Primary - 90% Secondary - 80% Data Quality & Clinical Coding Team (Cheshire & Merseyside)

28. Coding Issues – Incompleteness/Inaccuracies • Use of discharge summaries as the main source document – missing CCs • State of casenotes • Patient transfers • Training – coders must keep up-to-date • Insufficient internal audit • Insufficient involvement of clinicians Data Quality & Clinical Coding Team (Cheshire & Merseyside)

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32. Coding Issues - Timeliness • End of quarter/end of year catch up is not good enough for PBR • Must now meet ‘Flex’ and ‘Freeze’ dates • Issues affecting timeliness include: • - Source documentation • - Coding resources • - Training period (12 - 18 months) • - Recruitment and retention of staff Data Quality & Clinical Coding Team (Cheshire & Merseyside)

33. Source Documentation • Case notes to coders – need clerical support • Coders to case notes - problems working on wards • Proformas vs. case notes • Speed vs. depth of coding • Review final discharge letter for full accurate coding • But this means coding twice which impacts on resources Data Quality & Clinical Coding Team (Cheshire & Merseyside)

34. Coding Resources • 7,500 FCEs per WTE coder p.a. (additional requirement for OPD • Supervisor must be additional (role includes checking work of trainees, regular internal audits, training & development of all coders) • 12-18 month training period for new coders • Update training for experienced coders • Departmental structure Data Quality & Clinical Coding Team (Cheshire & Merseyside)

35. Coders’ Training Programme • Year 1 • Foundation Course with 6 and 12 month reviews • Year 2 • Anatomy & Physiology workshop • Specialty workshops • Year 3 • Refresher course • Preparation for Qualification Data Quality & Clinical Coding Team (Cheshire & Merseyside)

36. Recruitment and Retention of Coders • Appropriate grading structure • Agenda for Change • Appropriate selection criteria for new entrants • Opportunities for trained coders in primary care, information management, clinical audit, etc. • Acute trusts are the ‘training ground’ • Coders are worried about the future. Data Quality & Clinical Coding Team (Cheshire & Merseyside)

37. The Future • NCoI – impact of training & implementation period, need to recruit extra resources now • NHS Care Records Service • SNOMED CT • Templates, pick lists, cross mappings, etc. • The role of the coder will change over the next 10 years. • Coders will need to be supported with ETD and good leadership during the changes or PBR could be at risk Data Quality & Clinical Coding Team (Cheshire & Merseyside)

38. Final Thought Correct and complete Clinical Coding relies on both the skills of well trained coders and the provision of accurate information recorded in clinical records….. BUT - this is a trust wide responsibility, not just the coders. Data Quality & Clinical Coding Team (Cheshire & Merseyside)