Clinical Coding – The Clinicians’ role

1. Clinical Coding – The Clinicians’ role • This presentation has been produced by the NHS Classifications Service at NHS Connecting for Health. • It is intended that this presentation form the bases for the key messages that need to be given to the junior members of consultants’ teams in their induction day to ensure that they are aware of the need for accurate clinically coded data. This presentation is designed to last for approximately 7-10 minutes • Tutors notes and guidance have been supplied with this presentation. • Comments would be welcomed for future revisions. • NHS Classifications Service • NHS Connecting for Health • 2nd Floor Princes Exchange • Princes Square, • Leeds, • LS1 4HY • Version 1.0

2. Clinical CodingThe Clinicians’ Role Clinical Coding Department

3. What is Clinical Coding? • ‘… 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. (NHS Information Authority, Clinical Coding Instruction Manual)

4. Main Classifications • ICD-10 • International • Used to capture diagnostic clinical data • OPCS-4 • UK specific • Used to capture surgical interventions & procedures

5. Weekly Bills of MortalityLONDON week ending 31st January 1634The Diseases and Casualties this week • Abortive 2 • Aged 36 • Bedridden 1 • Bloody flux 1 • Bruised 1 • Cancer 1 • Chilbed 3 • Chrisoms 19 • Consumption 77 • Convulsions 44 • Cough 2 • Dropsie 1 • Executed 33 • Feaver 10 • Flox and smallpox 5 • Found dead in the street (an infant) 1 • French pox 1 • Gripping in the • guts 13 • Jaundies 1 • Infants 18 • Killed with a fall 3 • Murthered 1 Overlaid 2 Quinsie 1 Rickets 8 Rising of the lights 8 Scowering 1 Scurvey 2 Stillborn 9 Stone 1 Stopping of the stomach 3 Suddenly 6 Teeth 16 Winde 3 Worms 1 Males 107 Christened Female 109 In all 216 Males 213 Buried Females 196 In all409 Plague 0 Decreased in the buriels this week - 63 Parishes clear of the plague - 130 Parishes infected - 20 The assize of bread set forth by order of the Lord Mayor and Court of Aldermen A penny wheaten loaf to contain eleven ounces and a half and three halfpenny white loaves the like weight

6. Accuracy is reliant upon… • The Clinician providing the information on the patient’s diagnoses and treatment • The Clinical Coder translating that information into the appropriate coded format to reflect the patient’s hospital stay

7. Accurate and Complete Information • Complete diagnostic and procedural information is vital. • Hepatitis K75.9 Inflammatory liver disease, unspecified • Acute Hepatitis K72.0 Acute and subacute hepatic failure • Alcoholic Hepatitis K70.1 Alcoholic Hepatitis

8. Chest Pain ?MI Abdominal pain - possibly cholecystitis, possibly appendicitis Chest pain investigations confirmed MI Abdominal pain treated as appendicitis Possible and ? Diagnoses

9. Clinicians and Data Quality • The source documentation should: • Be accurate and complete • Reflect the patient’s episode of care • Avoid the use of abbreviations • Be clear and detailed • Recording is legible and in indelible ink

10. Clinical Statistical Uses of Clinical Coded Data Treatment effectiveness Clinical Governance Outcome measurement Clinical audit Cost analysis Health trends Commissioning Financial flows Epidemiological studies Aetiology studies Clinical Indicators Casemix planning

11. Florence Nightingale 1863 • "I am fain to sum up with an urgent appeal for adopting … some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life … In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison … If wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have means of ascertaining at present?" Florence Nightingale in Notes on Hospitals, London: Longman, Green, Roberts,Longman, and Green, 1863.

12. Important messages • The information that you write on the source documentation must: • Be complete and accurate • Reflect the patient’s episode of care • Avoid the use of abbreviations • Be clear and detailed • Recording is legible and in indelible ink • Anything that is unclear about a patient’s stay the Clinical Coding Department will clarify with the appropriate member of the consultant team to ensure accuracy in the clinically coded data.