Driving Clinical Coding Forward Data Quality for Improvement – the clinical coder’s perspective

1. Driving Clinical Coding ForwardData Quality for Improvement – the clinical coder’s perspective Jayne Harding Senior Clinical Classifications Advisor 24 November 2009

2. Clinical classifications: • The NHS Classification Service is the definitive source for clinical coding guidance and sets the national classifications standards in use in the NHS • Work collaboratively with NICE, Audit Commission, WHO and set the NHS Fundamental Information Standards

3. What is Clinical Coding? • Clinical coding is the translation of medical terminology, as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internationally recognised.

4. How?Using Classifications to code • ‘A classification is a systematic arrangement of like entities based on differing characteristics’ • Groups ‘like’ entities together in a standardised medical language • Provides a structured framework for statistical information • Governed by rules and conventions • Nationally and internationally recognised

5. Accuracy is reliant upon… • The Clinician providing all the information on the patient’s diagnoses and treatment dated and timed, with signature. • The Clinical Coder translating that information into the appropriate coded format to reflect the patient’s hospital stay.

6. What do coders use to code? • The information for coding comes from the ‘source document’ • The source document for coding varies from hospital to hospital but is usually the patient’s casenotes • This document includes: • discharge summaries / proformas • clinical work sheets • hospital to patient and hospital to GP documentation

7. Clinicians and Data Quality • The source documentation must: • Be clear and detailed - writing clearly in indelible ink • Provide accurate and complete information • Clearly record all diagnoses including co-morbidities and procedures, writing the main diagnosis first • Avoid abbreviations eg ‘M.S.’ could mean multiple sclerosis or mitral stenosis

8. Clinicians and Data Quality: • Sign and date every entry, print name and position • Ensure patient’s name is on every page • Let the admin staff know when you are removing notes • Every detail of the patient’s episode of care is important, including transfers

9. What your coders cannot do: • Guess: • Any ‘query’ diagnoses, or diagnoses preceded by a ‘?’ cannot be coded by clinical coding staff • Wait: • Coders must meet strict time deadlines to meet DH and audit requirements • Work alone: • They need clinical staff to collaborate

10. Support Coder • Understand their role • Start with junior doctor staff – train them early to collaborate with their coder effectively • http://www.connectingforhealth.nhs.uk/clinicalcoding/noncoders/clinicians • Support investment in coder’s training and development • Adopt the basic principles to ensure accurate coding

11. Ongoing - OPCS-4: • Harmonise more effectively with the clinical recording terminologies to maintain operability • Co-morbidities guidance refined and will be clinically driven • High level backing from DH to progress

12. The future - OPCS-4 e-book • Will reproduce the Tabular and Index • Hold national clinical coding standards including Coding Clinics • Comprehensive, search, navigation, retrieval • Receive updates automatically • Will support individual notes, annotations • Provide email functionality

13. Useful Contacts • Helpdesk and all queries: • datastandards@nhs.net • Website including resources for clinicians: • www.cfh.nhs.uk/clinicalcoding/noncoders • OPCS portal: • www.cfh.nhs.uk/opcsrequestsportal • Trud for releases: • https://www.uktcregistration.nss.cfh.nhs.uk.