Transcript Clinical Coding: accurate, timely, quality data – does it

Clinical Coding: accurate,
timely, quality data – does it
matter?
Christine Noonan
Principal Clinical Classifications Advisor
NHS Classifications Service
NHS Connecting For Health
March 2009
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
NHS Classifications Service
Cross
-maps
Developing classifications
Incl ICD-10 & OPCS-4
SNOMED-CT
HRG
NHS Classifications
standards
guidance & advice
Audit Methodology
SUS
Professional
Accreditation and training
DH initiatives
Care Record
Info Governance
Working to support the NHS
•
Strengthening NHS Clinical Coding Standards
•
Developing and maintaining standard coding audit
methodology
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Updating OPCS-4 classification
•
Training programmes
•
Information Governance
OPCS-4.5 mandated for use on 01-April-09
Summary of Changes:
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1.88% increase in number of codes from
OPCS-4.4
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new entries fall within existing chapters.
-
no change to the architecture of the clinical
classification
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most changes are seen in Trauma &
Orthopaedics
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new codes for spinal decompressions, fusions
and interventional radiology procedures
Training Courses currently available
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Chemo/Radiotherapy Workshop
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Anatomy & Oncology Workshop
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Clinical Coding Audit Workshop
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Clinical Coding Foundation Course
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Clinical Coding Refresher Course
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NCCQ Revision Workshop
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Train the Trainer Programme
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Trainer Refresher
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Bespoke Training including PCT Awareness
Audit Commission findings
Main issues identified as cause of clinical coding errors:
•
Quality of documentation
•
Coding arrangements
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Co-morbidity recording
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Lack of clinician involvement
•
Training issues
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
Where to start?
•
Explore what audit results mean for
Trusts
•
Identify how this will inform a data
quality programme
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
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
What you can do about it ?
•
Support coder education and
training
•
Address documentation issues
•
Engage clinicians ….. their
patients…. their data
Useful Contacts
•
For clinical coding queries, classification
training products, course bookings and
enquiries contact:
www.cfh.nhs.uk/clinicalcoding
[email protected]
•
For OPCS requests for change
www.cfh.nhs.uk/opcsrequestsportal