Clinical Coding: accurate, timely, quality data – does it matter?

Christine NoonanPrincipal Clinical Classifications AdvisorNHS Classifications ServiceNHS 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

Audit Methodology

HRGDeveloping classifications

Incl ICD-10 & OPCS-4

DH initiativesProfessional

Accreditation and training

SNOMED-CT

Info Governance

SUS

Care Record

NHS Classificationsstandards

guidance & advice

Working to support the NHS

• Strengthening NHS Clinical Coding Standards

• Developing and maintaining standard coding audit methodology

• Updating OPCS-4 classification

• Training programmes

• Information Governance

OPCS-4.5 mandated for use on 01-April-09

Summary of Changes:

- 1.88% increase in number of codes from OPCS-4.4

- new entries fall within existing chapters.

- no change to the architecture of the clinical classification

- most changes are seen in Trauma & Orthopaedics

- new codes for spinal decompressions, fusions and interventional radiology procedures

Training Courses currently available

- Chemo/Radiotherapy Workshop

- Anatomy & Oncology Workshop

- Clinical Coding Audit Workshop

- Clinical Coding Foundation Course

- Clinical Coding Refresher Course

- NCCQ Revision Workshop

- Train the Trainer Programme

- Trainer Refresher

- Bespoke Training including PCT Awareness

Main issues identified as cause of clinical coding errors:

• Quality of documentation

• Coding arrangements

• Co-morbidity recording

• Lack of clinician involvement

• Training issues

Audit Commission findings

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

datastandards@nhs.net

• For OPCS requests for change

www.cfh.nhs.uk/opcsrequestsportal