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

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

• Christine Noonan
• Principal Clinical Classifications Advisor
• NHS Classifications Service
• NHS Connecting For Health
• March 2009

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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

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NHS Classifications Service
Developing classifications Incl ICD-10 OPCS-4
HRG
Cross -maps
NHS Classifications standards guidance advice
SNOMED-CT
Audit Methodology
SUS
Professional Accreditation and training
DH initiatives
Care Record
Info Governance
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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

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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

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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

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Audit Commission findings

• Main issues identified as cause of clinical
  coding errors
• Quality of documentation
• Coding arrangements
• Co-morbidity recording
• Lack of clinician involvement
• Training issues

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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

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Where to start?

• Explore what audit results mean for Trusts
• Identify how this will inform a data quality
  programme

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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

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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

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What you can do about it ?

• Support coder education and training
• Address documentation issues
• Engage clinicians .. their patients. their data

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Useful Contacts

• For clinical coding queries, classification
  training products, course bookings and enquiries
  contact
• www.cfh.nhs.uk/clinicalcoding
• datastandards_at_nhs.net
• For OPCS requests for change
• www.cfh.nhs.uk/opcsrequestsportal