clinical coding audit report · score of 88.66%. 1.3 conclusions 1.3.1 the audit results provide...

Clinical Coding Audit Report

Cwm Taf University Local Health Board

Mrs Tracey Francis CCS Approved Clinical Coding Auditor,

NHS Wales Informatics Service

Mrs Helen Dennis ACC, CCS Approved Clinical Coding Auditor,


Mr Richard Burdon CCS Approved Clinical Coding Auditor,


Clinical Coding Audit – Cwm Taf ULHB

Document: 20190129-REP-Cwm Taf Clinical Coding Audit Report-2018-19.docx Date: 2019-05-13

Authors: Mrs. T. Francis, Mrs. H. Dennis, Mr. R Burdon (NWIS - Information Standards) Version:

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CONTENTS

1 Executive Summary ......................................................................................................................... 3

1.1 Introduction ............................................................................................................................ 3

1.2 Findings ................................................................................................................................... 3

1.3 Conclusions ............................................................................................................................. 4

1.4 Recommendations .................................................................................................................. 5

2 Introduction .................................................................................................................................... 6

3 Aims ................................................................................................................................................ 7

4 Objectives ....................................................................................................................................... 7

5 Background ..................................................................................................................................... 9

6 Methodology ................................................................................................................................. 14

7 Findings ......................................................................................................................................... 16

7.1 Total Percentages.................................................................................................................. 16

7.2 Unsafe to Audit (UTA) ........................................................................................................... 17

7.3 Primary Diagnosis Codes ....................................................................................................... 18

7.4 Secondary Diagnosis Codes Including External Cause Codes ............................................... 19

7.5 Primary Procedure Codes ..................................................................................................... 20

7.6 Secondary Procedure Codes ................................................................................................. 21

7.7 Health Record Findings ......................................................................................................... 22

8 Conclusions ................................................................................................................................... 23

9 Recommendations ........................................................................................................................ 24




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1 Executive Summary

1.1 Introduction

1.1.1 This audit represents part of an ongoing series of clinical coding accuracy audit reports,

produced as part of the national clinical coding audit programme of the NHS Wales

Informatics Service (NWIS).

1.1.2 This report outlines the findings and recommendations of NWIS’ Clinical Classifications &

Terminologies Standards Team audit of clinical coding accuracy at Cwm Taf University Local

Health Board.

1.2 Findings

1.2.1 Clinical coding departments are recommended to achieve the following percentages for

accuracy:

Primary Diagnosis ≥ 90%

Secondary Diagnosis ≥80%

Primary Procedure ≥90%

Secondary Procedure ≥80%

1.2.2 Below is a breakdown of the error rates achieved at Cwm Taf UHB:

Figure I Breakdown of Error Rates

Code Type Total Number of Codes Reviewed

Total Number of Correct Codes

Percentage Correct

Primary Diagnosis 320 291 90.94%

Secondary Diagnosis 1379 1307 94.78%

Primary Procedure 152 144 94.74%

Secondary Procedure 423 378 89.36%

1.2.3 The 2018/19 Welsh Government Clinical Coding Accuracy Measure score, outlined in

Appendix A, has been produced from the above figures, as follows:

Figure II Welsh Government Clinical Coding Accuracy Measure

Total Number of Codes


Accuracy Percentage

Cwm Taf ULHB 2274 2120 93.23%




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1.2.4 The above figure represents an improvement of 4.57% from the previous Accuracy Measure

score of 88.66%.

1.3 Conclusions

1.3.1 The Audit results provide assurance that the clinical coding at Cwm Taf ULHB is of a high

standard, achieving above the recommended accuracy rate in all four coding areas. The

organisation should be commended on its clinical coding accuracy.

1.3.2 Compared to the previous audit results there has been a significant increase (4.57%) in the

overall quality of clinical coded data at Cwm Taf ULHB.

1.3.3 The majority of the clinical coders at Cwm Taf ULHB are up to date with their required

training and they generally demonstrate a sound grasp of national clinical coding rules and

standards. However, there was evidence that some of the clinical coders were unaware of

the changes to the clinical coding standards that applied from 1st April 2018.

1.3.4 The evidence from this audit shows that a number of the clinical coding errors at Cwm Taf

were due to the clinical coding staff failing to abstract the clinical information from the

medical record required to assign accurate classification codes. The number and type of

errors identified in this audit indicate that the clinical coders at Cwm Taf are rushing the

clinical coding process. 72.60% of secondary diagnosis, 62.50% of primary procedure, and

91.11% of secondary procedure errors were errors of omission where the auditors found the

required information to be present within the medical record.

1.3.5 Seven of the twenty-nine primary diagnosis errors (24.14%) were sequencing errors. This

was due to the clinical coders misunderstanding, or failing to apply, the primary diagnosis

definition.

1.3.6 There were two primary diagnosis errors and five secondary diagnosis errors that could be

attributed to conflicting or unclear information within the patients’ medical records.

1.3.7 In an effort to speed up the clinical coding process in order to achieve their target of 40 FCEs

per day, the clinical coders at Cwm Taf are failing to consistently apply the full four step

coding process.

1.3.8 The clinical coding managers have made significant efforts with regard to the local policies in

use at Cwm Taf ULHB; however there are still a number of these local policies that are either

out of date or undated.




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1.3.9 The lack of a planned program of internal audits means that the only assurance of the

quality of clinical coded data at Cwm Taf is the annual Audit carried out by the NHS Wales

Classifications Standards and Terminology Team.

1.4 Recommendations

1.4.1 In order to consolidate and further improve the quality of the clinical coding data at Cwm Taf

UHB the auditors’ advise that the clinical coders at Cwm Taf continue to attend regular

training courses in order to retain and refresh their skills.

1.4.2 The clinical coding managers at Cwm Taf are advised to ensure that their clinical coding staff

are aware of any updates to the clinical coding standards and that they provide enough time

for the clinical coders to read, assimilate, and update their classification books with any

changes. They are further advised to support and encourage all their clinical coding staff to

attain the National Clinical Coding Qualification (NCCQ).

1.4.3 The clinical coders at Cwm Taf ULHB are advised whenever possible to reference the full

medical record and ensure they take the time to extract all the necessary information when

assigning classification codes. They are further advised to ensure that they are fully aware of

the primary diagnosis definition and that they consistently apply the full four step coding

process.

1.4.4 The auditor advises that immediate efforts be made to ensure that the staff within the Cwm

Taf UHB who have responsibility for clinical case notes are aware of the need for good

practice regarding their use. In particular, attention should be drawn to the Royal College of

Surgeons ‘Standards for Clinical Records’. Significant issues with individual case notes should

be highlighted using the relevant local incident reporting procedures in order to ensure that

attention is drawn to this issue and that possible clinical risks are being highlighted. In

particular, an investigation into the quality of the information provided on the DAL discharge

document is advised.

1.4.5 The clinical coding manager is advised to continue with their work reviewing the local

policies that are in use at Cwm Taf.

1.4.6. In order to facilitate an internal clinical coding audit programme, the management at Cwm

Taf ULHB is advised to continue with their plans to support one of the clinical coding staff to

undertake the NHS Digital Clinical Coding Audit Programme (CCAP).




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2 Introduction

2.1 The Admitted Patient Care data set (APC ds), and the clinically coded data contained within, is

arguably the single most important source of management information in use within NHS

Wales. The availability of timely, complete, accurately coded APC data are an essential pre-

requisite for numerous current and emerging decision support processes.

2.2 Welsh Local Health Boards (LHBs) and Velindre NHS Trust are mandated to clinically code the

finished consultant episodes (FCEs) for every patient admitted to a Welsh LHB. Organisations

are required to accurately code information relating to all diagnoses and procedures relevant

to each individual episode of care experienced by a patient.

2.3 Welsh LHBs and Velindre NHS Trust are currently monitored against a Welsh Government

(WG) performance measure for coding completeness. This target is that of 95% of all FCE’s are

clinically coded within one month of the episode end date.

2.4 The NHS Wales Outcomes Framework 2016-2017 introduced a new data quality standard

measuring clinical coding accuracy, which is outlined in the Clinical Coding Accuracy Measure

document in Appendix A.

2.5 Clinical coded data are used for a variety of uses and it impacts on a number of areas

including:

Healthcare planning (including service reconfiguration);

Performance management (notably the production of Tier 1 and other WG

performance indicators and measures);

Health needs assessment;

Evaluation of treatment and outcome analysis;

Benchmarking;

Chronic disease management (and the linkage of datasets);

Provision of information for research;

The production of official statistics and ad-hoc requests – Ministerial, Assembly

Questions, Freedom of Information etc.;

Financial costing and resource utilisation mapping;

Identification of at risk populations;

Identification of frequency and occurrence of disease;

The monitoring of (often high cost) services provided by the Welsh Health

Specialised Services Committee (WHSSC);




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Clinical coding data is central to a range of national information initiatives, such as

the annual financial costing process and patient-level costing;

2.6 It is current WG policy for healthcare data to be made more readily available to the general

public, media etc. under its ‘transparency’ agenda. Where clinical coding information is being

shared, this will further raise the importance of that data being accurate, and the need for the

Service to be assured that this is the case.

2.7 It is a therefore a requirement that clinical coded data are accurate, consistent, complete and

coded in a timely fashion.

2.8 Clinical coding audit is currently the only means by which it is possible to assure the accuracy

of clinical coded data.

2.9 This report outlines the findings and recommendations of the NHS Wales Informatics Service

(NWIS) Clinical Classifications & Terminologies Standards Team audit of clinical coding

accuracy at Cwm Taf University Local Health Board. The audit was carried out 5th November

2018 and 28th November 2018 and was undertaken by Mrs Tracey Francis, ACC, CCS Approved

Clinical Coding Auditor, NHS Wales Informatics Service, Mr Richard Burdon, ACC, CCS

Approved Clinical Coding Auditor, NHS Wales Informatics Service and Mrs Helen Dennis, ACC,

CCS Approved Clinical Coding Auditor, NHS Wales Informatics Service.

3 Aims

3.1 The aim of this audit was to assess the accuracy of the clinically coded data produced by Cwm

Taf ULHB by comparing the codes assigned by the Clinical Coding Department against national

clinical coding standards.

3.2 This report aims to provide a benchmark that can be used by the Clinical Coding Department

within Cwm Taf ULHB, to identify areas for improvement within the organisation and aid in

the identification and planning of future training needs. Conclusions and recommendations

based on areas of both good and poor practice found are provided to achieve this.

3.3 It also aims to evaluate the quality of the source documentation used by the coders and the

local policies and procedures used at Cwm Taf ULHB.

4 Objectives

4.1 The objectives for the audit include a range of measures.

4.2 To assess the clinical coding data against national clinical coding standards;




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4.3 To identify and report areas of good and bad practice;

4.4 To review and assess the accuracy of the source documentation used for clinical coding;

4.5 To assess the level of clinical involvement with the Clinical Coding Department and to what

degree this impacts on the coding process and coding accuracy;

4.6 To make recommendations designed to support future improve in the accuracy of clinically

coded data within the UHB;

4.7 To highlight training issues within the department.




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5 Background

5.1 Cwm Taf ULHB has a total of four hospitals offering a variety of patient services. Two of these

hospitals have clinical coders working on site: Royal Glamorgan Hospital and Prince Charles

Hospital.

5.2 The Clinical Coding Department sits in the Performance and Information Directorate at Cwm

Taf. They have a Clinical Coding Policy Document, which was last updated in 2018. They have

eight local clinical coding policies at present (see Appendix B). However, two of these policies

are out of date and are not dated at all. In addition, Cwm Taf ULHB have three new local

policies that are currently being checked by clinicians prior to approval.

5.3 Clinical coding staff at Cwm Taf ULHB assign codes to episodes for all inpatients, day case and

regular day attender episodes for hospital sites within the Health Board.

5.4 Cwm Taf ULHB generated a total of 102,946 Finished Consultant Episodes (FCEs) in the

2016/17 financial year.

5.5 At the end of the 2016/17 financial year, the Clinical Coding Department of Cwm Taf ULHB

had a backlog of 2,089 Finished Consultant Episodes (FCEs), 1.99% of the total number of

FCEs.

5.6 At the time of the audit, Cwm Taf ULHB had one clinical coding manager vacancy and two

clinical coder vacancies. The management position has now been filled, and Cwm Taf ULHB

have recruited two trainee clinical coders.

5.7 Cwm Taf ULHB clinical coding staff are expected to code 40 FCE’s per 7.5-hour day. This is set

out in Cwm Taf ULHB Clinical Coding Policy Document.

5.8 Notes that require coding are filed in the clinical coding departments. They are organised by

the date that they arrive in the department, and prioritised for coding by the oldest date of

discharge. The clinical coders at Cwm Taff ULHB do not code by specialty and there is no

Outpatient or A&E coding carried out at the health board. They do, however, perform some

data quality checks. If, during the clinical coding process, the coders identify an error in the

information held on WPAS they inform the information department whose responsibility it is

to correct any discrepancies.

5.9 In general, the source document used for coding is the paper record together with any

electronic documentation available. However, day case endoscopy episodes are coded using




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only the information held on the electronic Endoscopy system. Similarly, admissions for the

Accident and Emergency Clinical Unit (AECU) are coded using only electronic letters.

5.10 One member of staff at Cwm Taf is involved in the mentoring of trainee clinical coders. They

spread their time equally between both sites. They are responsible for checking the work of

the trainee/novice coders until they meet the required competency.

5.11 Cwm Taf ULHB make use of both overtime and clinical coding contract coders with the aim of

reaching the mandatory completeness target set by Welsh Government.

5.12 Coding is carried out using the Welsh Patient Administration System (WPAS) and 3M’s

Medicode Clinical Encoder. Codes are assigned to episodes using both the ICD-10 5th Edition

and OPCS 4.8 classifications.

5.13 During the time of the audit, two of the clinical coding staff at Cwm Taf ULHB held the ACC

qualification. One of these has since left the health board and at the time of writing only one

of the clinical coding staff at Cwm Taf hold this qualification.

5.14 85% of the coders meet the minimum training requirements of having completed the Clinical

Coding Foundation Training Course and a Clinical Coding Refresher Training Course within the

last 3 years. The remaining members of staff are awaiting a place on the clinical coding

refresher course.

5.15 There are currently no CCS Approved Clinical Coding Trainers or Auditors on site. All the

department’s training needs are currently met by D&A Consulting; a commercial company

supplying clinical coding training who provide all training services to NHS Wales via a national

training contract agreed with the NHS Wales Informatics Service. However, there are plans for

one of the clinical coding staff at Cwm Taf to apply for admission to the NHS Digital Clinical

Coding Audit Programme (CCAP).

5.16 At the time of the audit, the Clinical Coding Department had one band 6 Clinical Coding

Manager, and a band 5 Clinical Coding Supervisor, with one based at each of the clinical

coding offices. There are a total of 16 (15.2 WTE) clinical coders. Of these, 6 (5.8 WTE) are

trainee / novice coders. Trainee coders at Cwm Taf are now initially employed on Annex U of

Agenda for Change, and will not progress to a Band 4 until they attain ACC status. To this end,

the clinical coding management at Cwm Taf ULB now have a structured, documented training

process in place (see Appendix E). Trainee coders follow a 30-week study plan and are given

between two and four hours of study time during their working hours.




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5.1 All clinical coding staff have regular PDRs. At present, individual audits of clinical coder’s work

do not form part of the PDR process.

5.2 The coding manager has access to a weekly validation report that identifies basic errors in the

coded data.

5.3 There is no internal clinical coding audit programme at Cwm Taf; however, the quality of the

clinical coded data is examined as part of the clinical audits for Chronic Obstructive Pulmonary

Disease and Heart Failure. Any errors in the clinical coding identified at these clinical audits

are fed back to the clinical coders and amendments to the codes actioned when needed. The

last external clinical coding audit was carried out during the month of November 2017 by CCS

Approved Clinical Coding Auditors from NHS Wales Informatics Service Clinical Classifications

& Terminologies Standards Team.

5.4 There is no routine clinical validation of the clinical coding at Cwm Taf and very little

interaction between clinicians and the clinical coding teams at Cwm Taf.

5.5 The recommendations from the previous report and compliance:

The management and staff of the clinical coding department at Cwm Taf ULHB should

be congratulated on the improvement in the quality of the clinical coded data.

Compliant

The clinical coding staff at Cwm Taf ULHB are also advised that they should continue

to attend regular training courses in order to retain and refresh their skills.

The clinical coding management at Cwm Taf ULHB has made significant effort

to comply with this recommendation and they have confirmed that 85% of

the staff are up to date with their required training.

Clinical coding staff must ensure that they are using the full four step coding process

at all times in order to ensure the correct assignment of codes. The clinical coding

management should undertake additional quality checks to ensure this is the case.

There is no documented evidence that that Cwm Taf ULHB have complied

with this recommendation. However, they have stated that they have

provided instruction and clarification on the standards effecting the coding of

signs and symptoms.

Cwm Taf ULHB Clinical Coding Management must review the quality of the

information provided from electronic sources including endoscopy sheets, in order to




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ensure that it is sufficient for the accurate assignment of classification codes;

particularly if the electronic record is used as the only source document.

The quality of the information provided from single source documents from

electronic sources continues to cause problems for clinical coders at Cwm Taf.

However, the clinical coding management has changed their advice to the

clinical coding staff. In order to ensure the clinical coded data is as accurate as

possible they are advised that rather than coding from a single electronic

document they should access all the information on the particular episode of

care that is held electronically.

All clinical coding staff at Cwm Taf ULHB should immediately undertake the Anatomy

& Physiology e-learning module produced by NHS Digital.

There is no documented evidence that Cwm Taf ULHB have complied with this

recommendation.

The clinical coders at Cwm Taf ULHB are advised to ensure that they take the time to

access all the information pertinent to an episode of care held within the medical

record when assigning classification codes.

The clinical coding staff at Cwm Taf ULHB have failed to comply with this

recommendation. The pressure on the clinical coding staff at Cwm Taf ULHB

to increase their productivity to 40 FCE’s per day makes compliance with this

recommendation extremely difficult.

The clinical coding management is advised to review the process used at Cwm Taf

ULHB in order to ensure that their trainees have reached a required level of

competence prior to working autonomously

Although the Clinical Coding Department at Cwm Taf ULHB now have a

documented, structured, training plan, at present they still have only one

mentor who splits her time between both sites. The compliance with this

recommendation remains problematic.

The clinical coding supervisor should immediately check and update the local policy

documents in use at Cwm Taf ULHB.

The clinical coding management at Cwm Taf have reviewed and updated

many of their local policies. However, there are a number that still require

attention.




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The auditors advise that the clinical coders at Cwm Taf immediately reacquaint

themselves with the primary diagnosis definition, available in the National Clinical

Coding Standards , ICD-10 5th Edition (April 2017) annual. In addition, it is also advised

that within the next three months they undertake both the ICD 10 Four Step Coding

Process e-learning module and the Anatomy and Physiology e-learning module, which

are available on line at the NHS Digital TRUD site.

There is no documented evidence that Cwm Taff ULHB has complied with this

recommendation.

Cwm Taf clinical coding management should hold a training session for staff in order

to review the clinical coding standards (including Welsh Standards) affecting the

assignment of the code for a personal history of a benign neoplasm of the digestive

tract.

There is no documented evidence that Cwm Taf ULHB has complied with this

recommendation.




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6 Methodology

6.1 The recommended minimum percentage of correct codes are:

90% for Primary Diagnosis and Primary Procedure;

80% for Secondary Diagnosis and Secondary Procedures.

6.2 In addition to the recommended minimum percentages of correct codes mentioned above,

the results of the audit are used to calculate the Welsh Government Clinical Coding Accuracy

Measure score. This is a Tier 1 performance measure, further outlined in Appendix A:

Figure III Welsh Government Clinical Coding Accuracy Measure

Performance Measure

Target Information Source

Reporting Frequency

Performance Measure

34 Percentage of clinical coding

accuracy attained in the NWIS

National Clinical Coding Accuracy

audit programme.

Annual improvement

NWIS Clinical Coding Audit

Reports

New (2016/17)

6.3 The audit was conducted according to the directives in the Welsh Clinical Coding Audit

Methodology, and the current NHS Digital Clinical Coding Audit Methodology 18/19 v12.0. A

brief summary is given below, but the full methodology is available at:

http://nww.nwisinformationstandards.wales.nhs.uk/clinical-coding-audit-methodology

6.4 The sample audited was 320 Finished Consultant Episodes (FCEs), which were randomly

generated from the activity data held within the Patient Episode Database for Wales (PEDW).

The sample audited were selected from episodes from the last full reported month submitted,

as set out below:

Figure IV Period Examined

Site Period Start Period End

Royal Glamorgan Hospital 01/07/2018 31/07/2018

Prince Charles Hospital 01/08/2018 31/08/2018

6.5 The locally assigned classification codes were audited against national clinical coding

standards using the information available in the patients’ case notes and relevant electronic

systems (e.g. RADIS). Full details on the Clinical Coding National Standards are available at:




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http://nww.nwisinformationstandards.wales.nhs.uk/welsh-clinical-coding

6.6 The auditors then assessed the locally coded data against the National Clinical Coding

Standards and the Welsh Clinical Coding Standards using ICD-10 5th Edition and OPCS 4.8

classifications. Codes were audited as one of 4 types:

Primary Diagnosis codes (i.e. the main condition treated);

Secondary Diagnosis codes (including External Cause Codes and Morphology Codes);

Primary Procedure codes;

Secondary Procedure codes (including Chapter Z site codes).

6.7 A total of 320 episodes were examined.




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7 Findings

7.1 Total Percentages

7.1.1 The percentages of correctly assigned codes are given below:

Figure V Percentage of Codes Correctly Assigned

Code Type Total Number of Codes


Percentage Correct

Primary Diagnosis 320 291 90.94%

Secondary Diagnosis 1379 1307 94.78%

Primary Procedure 152 144 94.74%

Secondary Procedure 423 378 89.36%

7.1.2 The percentage of codes that were correct was above the recommended level in all 4 areas.

7.1.3 It should be noted that of the 320 episodes examined, 227 (70.94%), contained no errors in

any position. A breakdown of the error types assigned is given below.

7.1.4 The table below shows these results compared to previous audits:

7.1.5 The Welsh Government Clinical Coding Accuracy Measure score for 2017/18, as outlined in

Appendix A, is shown below:

Figure VI Overall Accuracy

Total number of codes

Total number of correct codes

Accuracy Percentage

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Primary Diagnosis Secondary Diagnosis Primary Procedure Secondary Procedure

Percentage Correct

2016 2017 2018




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Cwm Taf ULHB 2274 2120 93.23%

7.1.6 The table below shows these results compared to previous accuracy measure results:

7.2 Unsafe to Audit (UTA)

7.2.1 There were no episodes that were marked as UTA. The Clinical Coding Manager had ensured

that there were no episodes unsafe to audit, as the medical records had been checked to

ensure that the documents pertaining to the episode to be audited were present within the

notes.

86%

87%

88%

89%

90%

91%

92%

93%

94%

2017 2018

Accuracy Measure

Cwm Taf ULHB All Wales




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7.3 Primary Diagnosis Codes

7.3.1 The primary diagnosis was correct in 90.94% of the episodes audited (291 of the 320 primary

diagnoses). A breakdown of the errors in primary diagnoses by their associated error types is

given below:

Figure VII Primary Diagnosis Errors by Error Type

Error Type Specific Error Key Number of Errors

Percentage of FCEs with

Error

Coder Error PD3 PRIMARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL

12 3.75%

PD4 PRIMARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL

7 2.19%

PDIS PRIMARY DIAGNOSIS INCORRECTLY SEQUENCED

7 2.19%

PDO PRIMARY DIAGNOSIS OMITTED 1 0.31%

Documentation Issues

PDD PRIMARY DIAGNOSIS DOCUMENTATION ISSUE

2 0.63%




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7.4 Secondary Diagnosis Codes Including External Cause Codes

7.4.1 The secondary diagnoses codes were 94.71% correct (1307 out of the total 1380 secondary

diagnoses). A breakdown of the errors by their associated error types is given below:

Figure VIII Secondary Diagnosis Errors by Error Key



Error

Coder Error SD3 SECONDARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL

6 0.44%

SD4 SECONDARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL

4 0.29%

SD5 SECONDARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL

0 0%

SDNR SECONDARY DIAGNOSIS NOT RELEVANT

21 N/A

SDO SECONDARY DIAGNOSIS OMITTED 53 3.84%

ECI EXTERNAL CAUSE CODE INCORRECT 2 0.15%

ECO EXTERNAL CAUSE CODE OMITTED 2 0.15%

Documentation Issues

SDD SECONDARY DIAGNOSIS DOCUMENTATION ISSUE

5 0.36%




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7.5 Primary Procedure Codes

7.5.1 There were 152 primary procedure codes assigned. The primary procedure was correct in

94.74% of the episodes audited (144 of the 152 primary procedures). A breakdown of the

errors by their associated error types are shown below:

Figure IX Primary Procedure Errors by Error Key



Error

Coder Error PP3 PRIMARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL

1 0.66%

PP4 PRIMARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL

2 1.32%

PPNR PRIMARY PROCEDURE NOT RELEVANT

1 N/A

PPO PRIMARY PROCEDURE OMITTED 5 3.29%




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7.6 Secondary Procedure Codes

7.6.1 There were 423 secondary procedures codes assigned. These secondary procedure codes

were 89.36% correct (378 out of the 423 secondary procedures). A breakdown of the errors

by their associated error types are shown below:

Figure X Secondary Procedure Errors by Error Key



Error

SP4 SECONDARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL

4 0.95%

SPNR SECONDARY PROCEDURE NOT RELEVANT

3 N/A

SPO SECONDARY PROCEDURE OMITTED 41 10.64%




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7.7 Health Record Findings

7.7.1 The physical case notes used in his audit were generally in a good condition. However,

extracting the necessary information from larger and multiple volumes was more

problematic. In addition, it was apparent that essential information required for the

accurate assignment of classification codes was not always present on the discharge advice

letter (DAL) used at Cwm Taf. There were at least three errors in the diagnostic coding at

Cwm Taf that could be attributed to information missing from these documents.

7.7.2 The clinical coders a Cwm Taf rely on some single source documents when assigning

classification codes. Unfortunately, the information on these single source documents is not

always complete and /or accurate.




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8 Conclusions

8.1 The Audit results provide assurance that the clinical coding at Cwm Taf ULHB is of a high

standard, achieving above the recommended accuracy rate in all four coding areas. The

organisation should be commended on its clinical coding accuracy.

8.2 Compared to the previous audit results there has been a significant increase (4.57%) in the

overall quality of clinical coded data at Cwm Taf ULHB.

8.3 The majority of the clinical coders at Cwm Taf ULHB are up to date with their required training

and they generally demonstrate a sound grasp of national clinical coding rules and standards.

However, there was evidence that some of the clinical coders were unaware of the changes to

the clinical coding standards that applied from 1st April 2018.

8.4 The evidence from this audit shows that a number of the clinical coding errors at Cwm Taf

were due to the clinical coding staff failing to abstract the clinical information from the

medical record required to assign accurate classification codes. The number and type of errors

identified in this audit indicate that the clinical coders at Cwm Taf are rushing the clinical

coding process. 72.60% of secondary diagnosis, 62.50% of primary procedure, and 91.11% of

secondary procedure errors were errors of omission where the auditors found the required

information to be present within the medical record.

8.5 Seven of the twenty-nine primary diagnosis errors (24.14%) were sequencing errors. This was

due to the clinical coders misunderstanding, or failing to apply, the primary diagnosis

definition.

8.6 There were two primary diagnosis errors and five secondary diagnosis errors that could be

attributed to conflicting or unclear information within the patients’ medical records.

8.7 In an effort to speed up the clinical coding process in order to achieve their target of 40 FCEs

per day, the clinical coders at Cwm Taf are failing to consistently apply the full four step

coding process.

8.8 The clinical coding managers have made significant efforts with regard to the local policies in

use at Cwm Taf ULHB; however there are still a number of these local policies that are either

out of date or undated.

8.9 The lack of a planned program of internal audits means that the only assurance of the quality

of clinical coded data at Cwm Taf is the annual Audit carried out by the NHS Wales

Classifications Standards and Terminology Team.




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9 Recommendations

9.1 In order to consolidate and further improve the quality of the clinical coding data at Cwm Taf

UHB the auditors’ advise that the clinical coders at Cwm Taf continue to attend regular

training courses in order to retain and refresh their skills.

9.2 The clinical coding managers at Cwm Taf are advised to ensure that their clinical coding staff

are aware of any updates to the clinical coding standards and that they provide enough time

for the clinical coders to read, assimilate, and update their classification books with any

changes. They are further advised to support and encourage all their clinical coding staff to

attain the National Clinical Coding Qualification (NCCQ).

9.3 The clinical coders at Cwm Taf ULHB are advised whenever possible to reference the full

medical record and ensure they take the time to extract all the necessary information when

assigning classification codes. They are further advised to ensure that they are fully aware of

the primary diagnosis definition and that they consistently apply the full four step coding

process.

9.4 The auditor advises that immediate efforts be made to ensure that the staff within the Cwm

Taf UHB who have responsibility for clinical case notes are aware of the need for good

practice regarding their use. In particular, attention should be drawn to the Royal College of

Surgeons ‘Standards for Clinical Records’. Significant issues with individual case notes should

be highlighted using the relevant local incident reporting procedures in order to ensure that

attention is drawn to this issue and that possible clinical risks are being highlighted. In

particular, an investigation into the quality of the information provided on the DAL discharge

document is advised.

9.5 The clinical coding manager is advised to continue with their work reviewing the local policies

that are in use at Cwm Taf.

9.6 In order to facilitate an internal clinical coding audit programme, the management at Cwm Taf

ULHB is advised to continue with their plans to support one of the clinical coding staff to

undertake the NHS Digital Clinical Coding Audit Programme (CCAP).




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Appendix A Clinical Coding Accuracy Measure

The NHS Wales Outcomes Framework 2016-2017 introduced a new data quality standard measuring

clinical coding accuracy:

Performance Measure

Target Information Source

Reporting Frequency

Performance Measure

34 Percentage of clinical coding accuracy attained in the NWIS national clinical coding accuracy audit programme

Annual improvement

NWIS Clinical Coding Audit Reports

New

Each organisation must be able to demonstrate an annual improvement in the level of their clinical

coding accuracy; this will be measured via the national clinical coding audit programme. Currently

this programme measures the accuracy of the code assignments by looking at four specific areas –

primary diagnosis, secondary diagnosis, primary procedure, and secondary procedure. Each of these

areas is given a percentage accuracy rating in order to allow coding departments to identify specific

areas of good practice, or which require improvement.

In order to provide a single accuracy measure the codes investigated in the audit are not separated

out by their position in the medical record (i.e. primary diagnosis, secondary diagnosis, primary

procedure, and secondary procedure). Instead, the total number of codes reviewed during the audit

is used as the denominator, with the numerator being the total number of those codes the auditors

have judged to be correctly assigned. The table below shows the results for Cwm Taf ULHB since the

inception of the measure in 2016/17, as well as the all-Wales results in each year for comparative

purposes:

Total number of codes

Total number of correct codes

Accuracy Percentage

Cwm Taf ULHB (2017/18)

2275 2120 93.19%

All Wales (2017/18) 17,929 16,438 91.68%

Cwm Taf ULHB (2016/17)

1737 1352 77.84%

All Wales (2016/17) 88.79%




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Appendix B Cwm Taf ULHB Local Policies and Procedures

AAA.pdf Forceps_vacuum_deli

very.pdf

Haemorrhagic_infarct

_strokes.pdf

Hybrid_hip_replacem

ent_cement.pdf

Labial_graze.pdf

Lag_screws.pdf POTS.pdf Pseudogout.pdf Surgical_removal_wis

dom_teeth.pdf




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Appendix C Error key examples

Primary Diagnosis Errors

Primary Diagnosis Incorrect at 3rd Character Level (PD3)

There were twelve primary diagnosis errors (3.75%) incorrect at 3rd character level.

Figure I PD3 Example:

UHB Coding Auditor Coding

H26.9 Cataract, unspecified H25.1 Senile nuclear cataract

H04.1 Other disorder of lacrimal gland J45.9 Asthma, unspecified

I10.X Essential (primary) hypertension Z86.7 Personal history of diseases of the

circulatory system

J45.9 Asthma, unspecified

Z88.0 Personal history of allergy to penicillin

Z92.2 Personal history of long term (current) use

of other medicaments

Z86.7 Personal history of diseases of the

circulatory system

The information within the medical record for this episode of care stated that the cataract was

specified to be nuclear sclerotic. This clinical statement can be indexed to H25.1 Senile nuclear

cataract. The clinical coding standards state that each problem should be coded to the furthest level

of specificity available in the classification and supported by the medical record.1,2,3

Primary Diagnosis Incorrect at 4th Character Level (PD4)

There were seven primary diagnosis errors (2.19%) incorrect at 4th character level.

Figure II PD4 Example:


L03.9 Cellulitis, L03.1 Cellulitis of other part of limb

1 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 2 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 3 Ref - Data Quality - Three Dimensions of Coding Accuracy -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9




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W57.9 Bitten or stung by nonvenomous insect

and other nonvenomous arthropod, Unspecified

place


and other nonvenomous arthropod, Unspecified

place

M79.66 Pain in limb, Lower leg M79.66 Pain in limb, Lower leg

The information within the medical record for this episode of care stated that the cellulitis was of

the thigh. The clinical coding standards state that each problem should be coded to the furthest level

of specificity available in the classification and supported by the medical record.4,5,6

Primary Diagnosis Incorrectly Sequenced (PDIS)

There were seven primary diagnosis errors (2.19%) which were incorrectly sequenced.

Figure III PDIS Example:


R10.3 Pain localized to other parts of the lower

abdomen

N83.2 Other and unspecified ovarian cyst

N83.2 Other and unspecified ovarian cyst K62.8 Other specified diseases of anus and

rectum

K62.8 Other specified diseases of anus and

rectum

Z90.4 Acquired absence of other parts of digestive

tract

Z90.4 Acquired absence of other parts of

digestive tract

K59.0 Constipation

The information in the medical record for this episode of care stated that the pain was a symptom of

the ovarian cyst. The clinical coding standards state that the first diagnostic field of the clinical coded

record should contain the main condition treated or investigated during the relevant episode of

care. In addition, the clinical coding standards state that the clinical coder is required to assign the

minimum number of codes that accurately reflect the patient condition during the consultant

4 Ref - Data Quality - Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 5 Ref – Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 6 Ref - Data Quality- Three Dimensions of Coding Accuracy -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9




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episode. The clinical coding standards also states if a diagnosis is identified from a sign, symptom, or

abnormal finding then the code for the specific diagnosis must be assigned instead.7,8,9,10,11

Primary Diagnosis Omitted (PDO)

There was one primary diagnosis omission errors (0.31%).

Figure IV PDO Example:


R07.4 Chest pain, unspecified T40.2 Poisoning by narcotics and

psychodysleptics [hallucinogens] Other opioids)

Y45.0 Opioids and related analgesics X42.0 Accidental poisoning by and exposure to

narcotics and psychodysleptics [hallucinogens],

not elsewhere classified Home

Y45.5 4-Aminophenol derivatives T39.1 Poisoning by nonopioid analgesics,

antipyretics and antirheumatics 4-Aminophenol

derivatives

R06.0 Dyspnoea X40.0 Accidental poisoning by and exposure to

nonopioid analgesics, antipyretics and

antirheumatics Home

Y45.0 Opioids and related analgesics R07.4 Chest pain, unspecified

Y45.5 4-Aminophenol derivatives R11.X Nausea and vomiting

R11.X Nausea and vomiting R06.0 Dyspnoea

Y45.0 Opioids and related analgesics F55.X Abuse of non-dependence-producing

substances

Y45.5 4-Aminophenol derivatives

F55.X Abuse of non-dependence-producing

substances

7 Ref - DGCS.1 : Primary Diagnosis - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 28 8 Ref - Data Quality- Medical Record - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 9 Ref - Data Quality- Coding Uniformity - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 10 Ref - Data Quality- Three Dimensions of Coding Accuracy - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 11 Ref – DChS.XVIII.1: Signs, symptoms and abnormal laboratory findings - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 172




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The information within the medical record for this episode of care stated that the patient took their

mother’s medication. The medication was not meant for this patient, and therefore was improperly

used. In this scenario, it should have been coded as an accidental poisoning, rather than an adverse

effect in therapeutic use. The clinical Coding Standards state that a poisoning should be assigned a

code from Chapter XIX for the substance causing the poisoning. The clinical coding standards also

state that poisoning, not documented as either accidental or self-harm, should be coded to

accidental poisoning.12,13,14

Primary Diagnosis Documentation Issue (PDD)

There were two primary diagnosis errors (0.63%) due to documentation issues.

Figure V PDD Example:


F05.9 Delirium, unspecified I63.5 Cerebral infarction due to unspecified

occlusion or stenosis of cerebral arteries

R53.X Malaise and fatigue F05.9 Delirium, unspecified

N17.9 Acute renal failure, unspecified R53.X Malaise and fatigue

R29.6 Tendency to fall, not elsewhere classified N17.9 Acute renal failure, unspecified

I10.X Essential (primary) hypertension R29.6 Tendency to fall, not elsewhere classified

E11.9 Type 2 Diabetes mellitus Without

complications

I10.X Essential (primary) hypertension

E11.9 Type 2 Diabetes mellitus Without

complications

The information within the medical record for this episode of care contained conflicting information.

The discharge summary did not contain any information with regard to diagnosis or procedures, it

contained only the details of the patient’s take home medications. The conclusion on the report for

the computed tomography of the head stated “lacunar infarction”, but also stated “old?” At the end

of the episode, a clinical statement of “lacunar infarction” was documented. The clinical coding

standards state that each problem should be coded to the furthest level of specificity available in the

12 Ref - Data Quality- Medical Record - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 13 Ref - Data Quality- Coding Uniformity - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 14 Ref – DCS.XIX.8: Poisoning (T36 – T65) - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 195




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classification and supported by the medical record. In addition, the clinical coding standards also

gives explicate instruction on which code to assign for a diagnostic statement of lacunar infarction.

15,16,17,18

15 Ref - Data Quality- Medical Record - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 16 Ref - Data Quality- Coding Uniformity - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 17 Ref - Data Quality- Three Dimensions of Coding Accuracy - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 18 Ref – DCS.IX.11: Stroke not specified as haemorrhage or infarction (I64.X) and Lacunar infarction (I63.5)




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Secondary Diagnosis Errors

Secondary Diagnosis Incorrect at 3rd Character Level (SD3)

There were six secondary diagnoses (0.44%) incorrect at 3rd character level.

Figure VI SD3 Example:


J18.1 Lobar pneumonia, unspecified J18.1 Lobar pneumonia, unspecified

N17.9 Acute renal failure, unspecified N17.9 Acute renal failure, unspecified

I48.0 Paroxysmal atrial fibrillation I48.0 Paroxysmal atrial fibrillation

Z85.3 Personal history of malignant neoplasm of

breast

Z85.3 Personal history of malignant neoplasm of

breast

I10.X Essential (primary) hypertension I95.9 Hypotension, unspecified

E78.0 Pure hypercholesterolaemia E78.0 Pure hypercholesterolaemia

M35.3 Polymyalgia rheumatica M35.3 Polymyalgia rheumatica

R29.6 Tendency to fall, not elsewhere classified R29.6 Tendency to fall, not elsewhere classified

E86.X Volume depletion E86.X Volume depletion

I67.8 Other specified cerebrovascular disease I67.8 Other specified cerebrovascular disease

Z86.7 Personal history of diseases of circulatory

system

Z86.7 Personal history of diseases of circulatory

system

The information within the medical record for this episode of care stated that the patient had

hypotension; unfortunately, the clinical coder assigned the code for hypertension in error. The

clinical coding standards state that each problem should be coded to the furthest level of specificity

available in the classification and supported by the medical record.19,20,21

19 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 20 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 21 Ref - Data Quality- Three Dimensions of Coding Accuracy -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9




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Secondary Diagnosis Incorrect at 4th Character Level (SD4)

There were four secondary diagnoses (0.29%) incorrect at 4th character level.

Figure VII SD4 Example:


A41.9 Sepsis, unspecified A41.9 Sepsis, unspecified

J18.9 Pneumonia, unspecified J18.1 Lobar pneumonia, unspecified

J44.0 Chronic obstructive pulmonary disease

with acute lower respiratory infection

J44.0 Chronic obstructive pulmonary disease with

acute lower respiratory infection

F17.1 Mental and behavioural disorders due to

use of tobacco Harmful use



M17.9 Gonarthrosis M17.9 Gonarthrosis

M47.9 Spondylosis M47.9 Spondylosis

E78.5 Hyperlipidaemia E78.5 Hyperlipidaemia

M77.1 Lateral epicondylitis M77.1 Lateral epicondylitis

M10.9 Gout, unspecified M10.9 Gout, unspecified

E11.9 Type 2 diabetes mellitus E11.9 Type 2 diabetes mellitus

Z82.3 Family history of stroke Z82.3 Family history of stroke

The information in the medical for this episode of care stated that there was pneumonia with

consolidation. This clinical statement is indexable in ICD-10 to J18.1 Lobar pneumonia, unspecified.

The clinical coding standards state that each problem should be coded to the furthest level of

specificity available in the standards and supported by the medical record. The clinical coding

standards also state that if the specific type of pneumonia is identified then the appropriate code

from categories J12.- to J18.- must be selected in preference to J18.9.22,23,24

22 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 23 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 24 Ref – DCS.X.5: COAD/COPD, chest infection and asthma with associated conditions.




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Secondary Diagnosis Not Relevant (SDNR)

There were twenty-one secondary diagnoses assigned which were not relevant.

Figure VIII SDNR Example:


O13.X Gestational [pregnancy-induced]

hypertension

O13.X Gestational [pregnancy-induced]

hypertension

Z37.0 Single live birth Z37.0 Single live birth

O48.X Prolonged pregnancy F17.1 Mental and behavioural disorders due to




There was no indication in the medical record for this episode of care that the patient was post-

term or post-dates. The length of the pregnancy was documented as 41 +1. The clinical coding

standards state that the code O48.X Prolonged pregnancy should only be assigned if the pregnancy

is documented to be over 42 weeks, or the responsible consultant has documented post-term or

post-dates.25,26

Secondary Diagnosis Omitted (SDO)

There were fifty-three secondary diagnoses (3.84%) omitted.

Figure IX SDO Example:


P36.9 Bacterial sepsis of new-born, unspecified P36.9 Bacterial sepsis of new-born, unspecified

Z38.0 Singleton, born in hospital Z38.0 Singleton, born in hospital

P70.4 Other neonatal hypoglycaemia P70.4 Other neonatal hypoglycaemia

P80.8 Other hypothermia of new-born P80.8 Other hypothermia of new-born

P05.9 Slow fetal growth, unspecified P07.1 Other low birth weight

P07.3 Other preterm infant

P59.0 Neonatal jaundice associated with preterm

delivery

25 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 26 Ref – DCS.XV.20: Prolonged pregnancy (O48.X) - National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 153




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P05.9 Slow fetal growth, unspecified

A number of important comorbidities were omitted from the clinical coding record for this episode

of care. The clinical coding standards state that the clinical coder should assign classification codes

for every condition that effects the care during a consultant episode that is available in the

classification and supported by the medical record. In addition, the clinical coding standards also

state that when a condition classifiable to categories P07 or P08 and a condition classifiable to

category P05 are present, both codes must be assigned.27,28,29,30

External Cause Code Incorrect (ECI)

There were two incorrect external cause codes assigned (0.15%).

Figure X ECI Example:


S01.0 Open wound of scalp S01.0 Open wound of scalp

W01.4 Fall on same level from slipping, tripping

and stumbling Street or highway

X59.4 Exposure to unspecified factor Street or

highway


use of alcohol Acute intoxication


use of alcohol Acute intoxication


use of alcohol Dependence syndrome


use of alcohol Dependence syndrome

R45.8 Other symptoms and signs involving

emotional state

R45.8 Other symptoms and signs involving

emotional state

There was no indication in the medical record for this episode of care that the mechanism of their

injury was a fall. In fact, the medical record did not provide any details of the mechanism of the

injury at all. The clinical coding standards state that when the external cause of the injury is not

specified then the code X59. - Exposure to unspecified factor should be assigned.31,32,33

27 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 28 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 29 Ref - Data Quality- Three Dimensions of Coding Accuracy -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 30 Ref - DCS.XVI.2: Disorders related to length of gestation and fetal growth (P05 – P08) 31 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 32 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 33 Ref - DChS.XX.1: External Causes -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 201




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External Cause Code Omitted (ECO)

There were two external cause codes omitted (0.15%).

Figure XI ECO Example:


L03.1Cellulitis of other parts of limb L03.0 Cellulitis of finger and toe

L03.0 Cellulitis of finger and toe L03.1Cellulitis of other parts of limb


and other nonvenomous arthropod Other

specified places

The information within the medical record for this episode of care stated that the cellulitis was

caused by the bite of a horse fly. The clinical coding standard state that an external cause code must

be assigned and sequenced after the code that identifies the resulting condition.34,35,36

Secondary Diagnosis Documentation Issue (SDD)

There were five secondary diagnosis errors (0.36%) due to documentation issues.

Figure XII SDD Example:


M54.5 Low back pain M54.5 Low back pain

M47.9 Spondylosis, unspecified

J44.9 Chronic obstructive pulmonary disease,

unspecified

I10.X Essential (primary) hypertension

M81.9 Osteoporosis, unspecified

M85.8 Other specified disorders of bone density

and structure

The clinical coder failed to assign the codes to identify a number of comorbidities for this episode of

care. All of these conditions were documented on the clinical letter giving details of the planned

34 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 35 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 36 Ref - DChS.XX.1: External Causes -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 201




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admission. However, they were not documented in the paperwork within the actual dates of the

admission. This caused confusion for the clinical coder, as they were not sure if they were relevant

to the episode being coded. The auditor confirmed that the clinical letter formed part of the

admission record for this episode of care and the documented comorbidities should be coded.37,38,39

37 Ref - Data Quality- Medical Record-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 6 38 Ref - Data Quality- Coding Uniformity-National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9 39 Ref - Data Quality - Three Dimensions of Coding Accuracy -National Clinical Coding Standards ICD-10 5th Edition (April 2018) – Page 9




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Primary Procedure Errors

Primary Procedure Incorrect at 3rd Character Level (PP3)

There was one primary procedures (0.66%) incorrect at 3rd character level.

Figure XIII PP3 Example:


S06.5 Excision of lesion of skin of head and neck

NEC

D02.1 Excision of lesion of external ear

Z20.1 External ear D06.4 Graft of skin to external ear

D06.4 Graft of skin to external ear Z94.2 Right sided operation

Z94.2 Right sided operation Y58.8 Harvest of skin for graft Other specified

Y58.8 Harvest of skin for graft Other specified Z48.2 Skin of neck

Z48.2 Skin of neck Z94.3 Left sided operation

Y84.2 Sedation NEC Y82.9 Local anaesthetic Unspecified

Y84.2 Sedation NEC

The clinical coder failed to follow the full four step coding process when assigning the primary

diagnosis code for this episode of care. They failed to follow the excludes note at the beginning of

Chapter S: Skin, which instructs the coder to use codes from Chapter D: Ear for operations on the

skin of external ear. The clinical coding standards state that each procedure must be coded to the

furthest level of specificity that is available in the classification and supported by the medical

record.40,41,42

Primary Procedure Incorrect at 4th Character Level (PP4)

There was one primary procedures (0.66%) incorrect at 4th character level.

Figure XIV PP4 Example:


W24.3 Closed reduction of fracture of long bone

and flexible internal fixation HFQ

W24.2 Closed reduction of fracture of long bone

and rigid internal fixation NEC

Z70.5 Lower end of radius NEC Z70.5 Lower end of radius NEC

40 Ref - Data Quality - Coding Uniformity – National Clinical Coding Standards OPCS-4 (2018)- Page 9 41 Ref - Data Quality - The Four Step Coding Process - National Clinical Coding Standards OPCS-4 (2018)- Page 10 42 Ref – PConvention 2: Instructional notes and Paired codes - National Clinical Coding Standards OPCS-4 (2018)- Page 24




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Z94.3 Left sided operation Z94.3 Left sided operation

Y80.4 Intravenous anaesthetic NEC Y80.4 Intravenous anaesthetic NEC

The information within the medical record for this episode of care stated that the fracture of the

radius was fixed using ‘k wires’. The clinical coding standards state that k wires are a type of rigid

fixation, but the clinical coder assigned the code for flexible fixation in error.43,44

Primary Procedure Incorrectly Sequenced (PPIS)

There was one primary procedures (0.66%) which were incorrectly sequenced.

Figure XV PPIS Example:


S57.3 Toilet of skin NEC S42.1 Primary suture of skin NEC

S42.1 Primary suture of skin NEC S57.3 Toilet of skin NEC

S50.4 Skin of leg NEC S50.4 Skin of leg NEC

Z94.2 Right sided operation O13.2 Knee NEC

Z94.2 Right sided operation

The information within the medical record for this episode of care confirmed that the main

procedure was the suture of the laceration.45,46,47

Primary Procedure Omitted (PPO)

There were five primary procedures (3.29%) omitted.

Figure XVI PPO Example:


U07.1 Computed tomography of chest

Y97.3 Radiology post contrast

Y98.1 Radiology one body area (or ˂ 20 minutes)

The information in the medical record for this episode of care stated that a CT of the chest was

carried out. The clinical coder failed to assign the OPCS-4 codes for this procedure. The clinical

43 Ref - Data Quality - Medical Record - National Clinical Coding Standards OPCS-4 (2018)- Page 7 44 Ref – PChSW1: K-Wire fixation - National Clinical Coding Standards OPCS-4 (2018)- Page 119 45 Ref - Data Quality - Medical Record - National Clinical Coding Standards OPCS-4 (2018)- Page 7 46 Ref - Data Quality - Coding Uniformity - National Clinical Coding Standards OPCS-4 (2018)- Page 9 47 Ref – PRule 2: Single procedure analysis and multiple coding - National Clinical Coding Standards OPCS-4 (2018)- Page 16




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coding standards state that the minimum number of codes that accurately reflect the interventions /

procedures should be assigned and that each procedure should have the correct code assignment. In

addition, the clinical coding standards also state that a computed tomography is one of the

diagnostic imaging procedures that must always be coded when performed.48,49,50

Primary Procedure Not Relevant (PPNR)

There was one primary procedure code assigned which was not relevant.

Figure XVII PPNR Example:


J44.9 Diagnostic endoscopic retrograde

examination of bile duct

There was nothing in the medical record for this episode of care to indicate that the patient had an

ERCP. The clinical coding standards state that the clinical coder should code the minimum number of

codes that accurately reflect the patient’s interventions / procedures.51,52,

48 Ref - Data Quality - Medical Record - National Clinical Coding Standards OPCS-4 (2018)- Page 7 49 Ref - Data Quality - Coding Uniformity - National Clinical Coding Standards OPCS-4 (2018)- Page 9 50 Ref - PCSU1: Diagnostic imaging procedures (U01 – U021 and U34 – U37) - National Clinical Coding Standards OPCS-4 (2018)- Page 100 51 Ref - Data Quality - Medical Record - National Clinical Coding Standards OPCS-4 (2018)- Page 7 52 Ref - Data Quality - Coding Uniformity - National Clinical Coding Standards OPCS-4 (2018)- Page 9




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Secondary Procedures

Secondary Procedure Incorrect at 4th Character Level (SP4)

There were four secondary procedures (0.95%) incorrect at 4th character level.

Figure XVIII SP4 Example:


V54.4 Injection around spinal facet of spine Code & Description

V55.9 Levels of spine Unspecified V55.1 One level of spine

Y53.4 Approach to organ under fluoroscopic

control

Y53.4 Approach to organ under fluoroscopic

control

Z67.5 Lumber intervertebral joint Z67.5 Lumber intervertebral joint

Z94.1 Bilateral operation Z94.1 Bilateral operation

The information within the medical record for this patient showed that this procedure was carried

out on one level of spine. The clinical coding standards state that each procedure should have the

correct code and that each code should be assigned to the furthest level of specificity available in

the classification and supported by the medical record.53,54,55

Secondary Procedure Omitted (SPO)

There were forty-one secondary procedures (9.69%) omitted.

Figure XIX SPO Example:


R22.2 Low vacuum delivery R22.2 Low vacuum delivery

R27.1 Episiotomy to facilitate delivery R27.1 Episiotomy to facilitate delivery

R14.1 Forewater rupture of amniotic membrane R14.1 Forewater rupture of amniotic membrane

R32.3 Repair of obstetric laceration of vagina

and floor of pelvis

R32.3 Repair of obstetric laceration of vagina and

floor of pelvis

Y84.2 Sedation NEC Y84.1 Gas and air analgesia in labour

R15.1 Medical induction of labour

The information within the medical record stated that the patient also had a medical induction of

labour, but the clinical coder failed to assign a code for this procedure. The clinical coding standards

53 Ref - Data Quality - Medical Record - National Clinical Coding Standards OPCS-4 (2018)- Page 7 54 Ref - Data Quality - Coding Uniformity - National Clinical Coding Standards OPCS-4 (2018)- Page 9 55 Ref - Data Quality – The Four Step Coding Process - National Clinical Coding Standards OPCS-4 (2018)- Page 10




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state that the minimum number of codes that accurately reflect the interventions / procedures

should be assigned and that each procedure should have the correct code assignment. 56,57

Secondary Procedure Not Relevant (SPNR)

There were three secondary procedure codes assigned which were not relevant.

Figure XX SPNR Example:


L91.2 Insertion of central venous catheter L91.2 Insertion of central venous catheter

Z98.8 Specified vein of lower limb Z98.8 Specified vein of lower limb

Z94.2 Right sided operation Z94.2 Right sided operation

U05.1 Computed tomography of head U05.1 Computed tomography of head

Y98.1 Radiology of one body area Y98.1 Radiology of one body area

X29.2 Continuous intravenous infusion of

therapeutic substance

The clinical coding standards state that the code X29.2 Continuous intravenous infusion of

therapeutic substance should only be assigned if the patient has been specifically admitted for the

infusion. Since this was not the case for this episode of care this code should not have been

assigned.58

56 Ref - Data Quality - Medical Record - National Clinical Coding Standards OPCS-4 (2018)- Page 7 57 Ref - Data Quality - Coding Uniformity - National Clinical Coding Standards OPCS-4 (2018)- Page 9 58 Ref – PCSX2: Intravenous infusions and intravenous injections - National Clinical Coding Standards OPCS-4 (2018)- Page 136




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Appendix D Responses to Queries

No queries were raised with the NHS Digital Audit Authentication Mechanism




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Appendix E Training Process

Clinical Coding Training Programme

It is the responsibility of the trainee coder to follow this training programme. The role of the Mentor

or Supervisor is to guide the learning and support the trainee to complete the programme. The time

schedule is a guide to be followed as much as possible in order to attain the required standards,

however it is intended to allow for some flexibility where necessary.

This training programme should be read in conjunction with the Health & Social Care Information

Centre (HSCIC) National Clinical Coding Training Handbook 2016/17.

Date Training

Week 1 - Discuss and agree training programme with the trainee

- Orientation/Local induction to the department

- Access to be arrange for WPAS (Myrddin) and External systems e.g. WCP/MITS

- IT Systems/ Myrddin training to be arranged

- Early familiarisation of case notes, their structure/organisation

- Register with HSCIC website

- Coding career information can be accessed and viewed using the link below:

https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=298067#298067

- Register with TRUD using link below:

https://isd.digital.nhs.uk/trud3/user/guest/group/0/home

Weeks

1-2

- Overview of coding classifications (ICD10 & OPCS)

- Study the 4 Step Coding process

- Complete the four step coding process eLearning option available on TRUD for

download:

https://isd.digital.nhs.uk/trud3/user/guest/group/0/search/results?q=e-learning

- The trainee gains 1-2 weeks experience in the Filing room in order to understand

the processes and procedures regarding Patient notes

https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=298067#298067

https://isd.digital.nhs.uk/trud3/user/guest/group/0/home

https://isd.digital.nhs.uk/trud3/user/guest/group/0/search/results?q=e-learning




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Weeks

2-3

Anatomy & Physiology

- Commence working through the chapters/sections within the A&P Manual,

including looking up medical terms, labelling diagrams and familiarisation with the

structure of medical terminology-prefix, suffix and root word

- Complete the A&P e-learning module on TRUD web page

- Encouragement of ‘googling’ unfamiliar terms encountered within the A&P Manual

TRUD website

- Familiarisation with the layout and how to find relevant information

- Coding Clinics – what they are and where to find them

Week 4 Commence Coding:

- Receive guidance on coding Endoscopies

- Commence coding diagnostics Endoscopies, starting with ‘examination’ and biopsy

- Gain experience in coding colonoscopies, sigmoidoscopies and OGD’s thereby

building confidence in assigning both ICD and OPCS codes

- All FCE’s to be audited by mentor, with results given back to trainee daily

Case note familiarisation:

- Examine how the case notes are structured and arranged.

- Gain an awareness of what documentation looks like along with what

documentation can be used

Coding query process in the department – (what to do when code assignment proves

difficult)

Week

4+

- Continue to build on accurately assigning OPCS and ICD codes to diagnostic

endoscopies

- Embark on gaining experience in coding therapeutic endoscopies

- Commence coding of assessment unit admissions.

- Continue to build on acquired skills with the appropriate introduction of more

complex notes when ready




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Clinical Coding Standards Course Pre-requisites

- Completion of both Standards Course Workbooks

These are: Coding Theory and Background and Coding Key Definitions

Month

2 – 6

- Trainee to attend Clinical Coding Standards Course within 2-6 months

- Other specialities to be added – starting with General Medicine, General Surgery

and Paediatrics

- Set coding figure with trainee of between 5-10 FCE’s per day

Months

7-12

- Continue to code across all specialties – including Orthopaedics, Gynaecology and

Obstetrics

- Coding figure to be increased to 10-15 FCE’s per day

Months

13-18

- Trainee to become competent in all other specialities, including Mental Health,

Vascular and Coronary Care (Mental Health – E-DALS to be printed for the trainee’s

use)

- Coding figure to be increased so that at the end of the 18 months the trainee is

competently coding 15 - 20 FCE’s per day over all specialities

- Continuous auditing of completed FCE’s and RIP’s

Months

19-24

- Review to evaluate sitting of NCCQ

- Coding figure to be increased to 25 FCE’s per day – to be made up of a case mix of

10 complex episodes of care and 15 easier

- All complex FCE’s coded to be audited/reviewed by mentor or auditor – until such

time as the trainee obtains ACC qualification

- Trainee to be included in the rolling individual audit programme

- Achieve ACC qualification

Months

24+

- Attendance of Refresher Workshop 2 years after completing the Standards Course

(and every three years thereafter). Continue to attend other Clinical Coding

workshops that are being hosted by NWIS.

clinical coding audit report · score of 88.66%. 1.3 conclusions 1.3.1 the audit results provide...

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