Clinical Coding Audit Assignment Report 2013/14. Hywel Dda University Health Board

Transcription

1 Clinical Coding Audit Assignment Report Hywel Dda University Health Board

2 Hywel Dda University Health Board Contents 1 Executive summary Introduction Background Scope & objective Policy & process Coding accuracy Diagnoses Primary diagnoses Secondary diagnoses Surgical procedures/interventions Primary procedure/intervention Secondary procedure/intervention Other coding issues Payment analysis Appendix A: Detailed coding assessment Appendix B: Recommendations Appendix C: Site analysis Appendix D: Audit approach Appendix E: Glossary of coding error codes Appendix F: Assurance and risk definitions Appendix G: Report data

3 Hywel Dda University Health Board 1. Executive Summary It is apparent from our work that the overall accuracy of clinical coding is of mixed quality with performance level that would only meet level one of Information Governance Toolkit (IG) Requirement 505 (NB. The Health Board is not required to submit IG Toolkit levels, and this is used purely as a means of benchmarking). The coding of the primary diagnosis was very good, but the accuracy of primary procedure fell 2.42% short of level two standards. The accuracy of the clinical coding is shown below: CODING FIELD PERCENTAGE CORRECT IG REQ 505 LEVEL 2 IG REQ 505 LEVEL 3 Primary diagnosis 92.86% 90% 95% Secondary diagnosis 84.88% 80% 90% Primary procedure 87.58% 90% 95% Secondary procedure 83.33% 80% 90% Good practice was noted in relation to the support the clinical coding function receives across the Health Board, with dedicated time provided for training, as well as the funding of a clinical coding auditor. While there are there are a number of opportunities to improve processes which will further improve accuracy as described within Appendix A, as a result of our findings the assurance level which we are able to provide in respect of clinical coding and underlying processes is: SIGNIFICANT ASSURANCE P a g e 1

4 Hywel Dda University Health Board 2. Introduction Accurate data quality and clinical coding are imperative to support patient care and to ensure the information is used for improving healthcare as well as contributing to effective management. To provide consistently recorded data, well-defined standards must be applied to allow comparisons to be made across time and between sources. The NHS uses the International Statistical Classifications of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Office Population Censuses and Surveys of Surgical Operations and Procedures, Fourth Revision (OPCS-4) as the standards for diagnostic and procedural coding. The data may be derived from Clinical Terms (the Read codes). The classifications provide the framework, using rules and conventions that, when applied accurately result in the provision of high quality, statistically meaningful data. Although Wales are not required to submit audit results for Information Governance (IG) purposes the Health Board decided that they would find benefit in following the guidelines as set out by IG Toolkit Requirement 505. IG Toolkit Version 11.0 was launched in April 2013 and, within that framework, requirement 505 states that trusts should have:- established documented procedures for the regular audit of clinical coding; carried out an internal clinical coding audit programme within the last twelve months which was based on the requirements and standards within the latest version of NHS Clinical Coding Audit Methodology and must have been undertaken by staff on the registered list of clinical coding auditors; and, where required, had an external clinical coding audit commissioned by the Audit Commission. This report provides an appraisal on the current position of Hywel Dda University Health Board in adhering to national clinical coding standards. The audit was based on the methodology detailed in the NHS Clinical Coding Audit Methodology Version 7.0. P a g e 2

5 Hywel Dda University Health Board 3. Background The Health Board deals with approximately 112,211 finished consultant episodes (FCEs) per year, which are all coded by the clinical coding staff using ICD-10 and OPCS-4 to generate clinical information of inpatient activity. This is broken down across site as follows: Site Finished consultant episodes Glangwili General Hospital 41,775 Prince Philip Hospital 19,450 Withybush General Hospital 32,230 Bronglais General Hospital 18,756 The coders, who are part of a centralised Clinical Coding Department within Planning and Performance, are responsible for the entire coding process, from abstraction through to input. There are whole time equivalent (WTE) clinical coders, inclusive of the Clinical Coding Manager and Supervisors. The clinical coding function across the four sites is made up from 25 coding staff, 10 of whom are accredited clinical coders (ACCs). The Clinical Coding Manager has responsibility across the four sites; there are Supervisors at two of the sites; the Health Board also employs a registered Clinical Coding Auditor, who assisted with the audit. The Health Board works to a formula for staffing levels of 6,600 FCEs per WTE. On the surface the current staffing is working to 5,340 FCEs per WTE, but the Clinical Coding Manager, Supervisors and Auditor do not have a full clinical coding workload to account for their other responsibilities. The source document used for the extraction of clinical coding data at the Health Board is the case note, supported by a discharge summary and proforma. P a g e 3

6 Hywel Dda University Health Board 4. Scope & objective To measure the quality of the clinical coding within the Health Board and to assist in improving the quality of clinical coding the objectives of the audit were:- To assess how well the coded data accurately reflects the diagnosis and procedures described in the clinical records; To focus on cardiology and general surgery with a portion of the sample covering miscellaneous specialties; To benchmark the accuracy against standards set out Information Governance Toolkit Requirement 505; To determine if the coding team thoroughly reviews appropriate source documents; To report errors in clinical coding assignments; To identify sources of clinical coding errors and make recommendations for correction; To identify any clinical coding training requirements; To determine the quality of the source documentation for the clinical coding function; To promote interchange between clinician and coder to improve the quality of coded data; and To further promote interaction with the Information Department, Finance Department and other function leads. P a g e 4

7 Hywel Dda University Health Board 5. Policy & process The Department has a Policy and Procedure document in place that is well structured, and supports the management and provision of information to all of the clinical coders via a shared drive. The document was last reviewed and updated in October 2013 and remains current. The Health Board uses the Medicode encoder; one issue relating to this is the resequencing of procedure codes when they are transferred from Medicode into the Myrddin Patient Administration System. The clinicians actively engage in the clinical coding process through various avenues. In Withybush General Hospital the clinicians validate the main diagnosis, and partially validate other diagnoses and procedures against the discharge letter. Elsewhere, the Clinical Coding Manager liaises with senior clinicians in the Health Board who have clinical roles in Informatics. Also the coders have access to clinicians to query clinical information and to ask advice about conditions and procedures. The Department has a programme of data quality accuracy checks that incorporate clinical coding; audits are performed monthly, if there are no staffing issues. The last external audit was carried out in P a g e 5

8 Hywel Dda University Health Board 6. Coding accuracy 6.1. Diagnoses Diagnostic information is required for the recording of both primary and secondary diagnoses for each episode of care. The definition of a primary diagnosis is: "The first diagnosis field(s) of the coded clinical record (the primary diagnosis) will contain the main condition treated or investigated during the relevant episode of healthcare. Where a definitive diagnosis has not been made by the responsible consultant the main symptom, abnormal finding or problem should be recorded in the first diagnosis field of the coded clinical record" 1. Therefore, on discharge the patient should be assigned a primary diagnosis even if a definitive diagnosis is not available. In addition to the primary diagnosis, all relevant secondary diagnoses should be recorded on the discharge front sheet. Secondary diagnoses should include: Conditions or problems dealt with during the episode of care Conditions, which pre-exist in the patient Patient status e.g. dependence on dialysis, etc. The secondary diagnoses should be recorded in order to accurately reflect the care received by the patient. 1 NHS Executive Health Service Guidelines HSG (96) September 1996 P a g e 6

9 Hywel Dda University Health Board Primary diagnoses Of the 252 episodes audited 234 (92.86%) primary diagnoses were coded correctly with errors categorised as depicted and detailed below. Primary diagnoses 1 17 Correct Non-coder error 234 Coder error Figure 1 Primary diagnosis coding analysis and error types The agreed errors that were identified in the audit comprised of: Non-coder errors (errors that are outside of the coders control and related to the documentation provided or a procedure in place) i. On one (0.40%) occasion the primary diagnosis was incorrect due to information being available to the auditor that was not available at the time of coding (PDI). Coder errors ii. iii. iv. One (0.40%) primary diagnosis was incorrect at three-character level (PD3). On four (2.78%) occasions the primary diagnosis was incorrect at fourth character level (PD4). On two (0.79%) occasions the condition the auditor deemed to be the primary diagnosis had been recorded by the coder but not sequenced in the primary position (PDIS). v. There were seven (2.78%) omitted primary diagnoses noted by the auditor (PDO). P a g e 7

10 Hywel Dda University Health Board Secondary diagnoses It is important that all relevant secondary diagnoses are recorded accurately in order to reflect the care provided to the patient during the relevant episode of care. Secondary diagnoses recorded should include additional conditions and complications arising during an episode of care, and pre-existing conditions, which require the continuing care of the patient during their episode of care. Of the 853 valid secondary diagnoses 724 (84.88%) were coded correctly with errors categorised as depicted and detailed below. Secondary diagnosis Correct 724 Non-coder error Coder error Figure 2 - Secondary diagnosis coding analysis and error types The agreed errors that were identified in the audit comprised of: Non-coder errors vi. Eight (0.94%) secondary diagnoses were incorrect due to information being available to the auditor that was not available at the time of coding (SDI). Coder errors vii. viii. ix. Eight (0.94%) secondary diagnoses were incorrect at three-character level (SD3). On 16 (1.88%) occasions the secondary diagnosis was incorrect at fourth character level (SD4). On 94 (11.02%) occasions a secondary diagnoses was omitted (SDO). P a g e 8

11 Hywel Dda University Health Board x. There were 18 unnecessary secondary diagnosis codes assigned (SDNR). xi. xii. xiii. One (0.12%) external cause code was recorded incorrectly (ECI). Two (0.23%) external cause codes had been omitted (ECO). Three unnecessary external cause codes had been recorded (ECNR). P a g e 9

12 Hywel Dda University Health Board 6.2. Surgical procedures/interventions Information regarding surgical procedures / interventions undertaken is required for every relevant episode of patient care, and should be documented on the discharge front sheet by the clinical staff responsible for the patient. According to OPCS-4.6 2, the definition of an intervention is: "...those aspects of clinical care carried out on patients undergoing treatment:- for the prevention, diagnosis, care or relief of disease; for the correction of deformity or deficit, including those performed for cosmetic reasons; associated with pregnancy, childbirth or contraceptive or procreative management. Typically this will be: surgical in nature; and/or carries a procedural risk; and/or carries an anaesthetic risk; and/or requires specialist training; and/or requires special facilities or equipment only available in an acute care setting It is generally considered that the procedure / intervention of most relevance should be selected as the primary procedure i.e. the main surgical operation in terms of complexity and use of resources. Secondary procedures / interventions are considered to include supplementary procedures / interventions such as diagnostic procedures or which are less complex than the main procedure. 2 OPCS Classification of Interventions and Procedures Version 4.6, TSO page viii P a g e 10

13 Hywel Dda University Health Board Primary procedure/intervention Of the 161 valid primary procedures 141 (87.58%) were coded correctly with errors categorised as depicted and detailed below. Primary procedure 1 22 Correct Non-coder error 141 Coder error Figure 3 - Primary procedure coding analysis and error types The agreed errors that were identified in the audit comprised of: Coder errors xiv. xv. xvi. Three (1.86%) primary procedures were incorrect at three-character level (PP3). Four (2.48%) primary procedures were incorrect at fourth character level (PP4). On two (1.24%) occasions the primary procedure described by the auditor had been recorded but not sequenced in the primary position (PPIS). xvii. On 11 (6.83%) occasions the primary procedure was omitted (PPO). xviii. Two unnecessary primary procedures had been recorded (PPNR). P a g e 11

14 Hywel Dda University Health Board Secondary procedure/intervention Of the 312 valid primary procedures 260 (83.33%) were coded correctly with errors categorised as depicted and detailed below. Secondary procedure 1 61 Correct 260 Non-coder error Coder error Figure 4 - Secondary procedure coding analysis and error types The agreed errors that were identified in the audit comprised of: Non-coder errors xix. One (0.32%) secondary procedure was incorrect due to information being available to the auditor that was not available at the time of coding (SPI). Coder errors xx. xxi. Five (1.60%) secondary procedures were incorrect at three-character level (SP3). On 11 (3.53%) occasions the secondary procedure was incorrect at fourth character level (SP4). xxii. One (0.32%) secondary procedure had been sequenced in a way that contravened a national clinical coding standard (SPIS). xxiii. On 34 (10.90%) occasions a secondary procedure code had been omitted (SPO). xxiv. 10 unnecessary secondary procedure codes had been recorded (SPNR). P a g e 12

15 Hywel Dda University Health Board 6.3. Other coding issues The Health Board performed to a mixed standard on audit, and from such a generalised audit the only concerns highlighted were: The auditors found a large number of omitted secondary diagnoses; contributing the more than any other error type found in the audit. These were all relevant to the episode of care with many relating to a national standard or classification rule. Information on endoscopy reports was occasionally misinterpreted, with incidental findings recorded as the primary diagnosis rather than the reason for the investigation, for example, a person investigated for weight loss having haemorrhoids being coded as the primary diagnosis when the report stated that this was not the cause. There were other occasions noted when incidental findings were not recorded. A standard 3 was introduced to clarify the use of fifth characters in Chapter XIII Disorders of the musculoskeletal system and connective tissue. This states that their use is mandatory where the data is present in the medical record, and where doing so adds more specific information. A fifth character of 9 was regularly assigned when the site of involvement was not known, but this is not deemed necessary. Medicode does bring up a command to assign a fifth character, but this can be bypassed by the coder. There were occasions when a diagnosis of left ventricular systolic dysfunction (or LVSD as it is abbreviated) was coded to I50.1 Left ventricular failure. The term itself cannot be trailed and the diagnosis is not uniformly accepted as a heart failure, and thus without a local policy to support it cannot be coded as such. The documentation relating to haemorrhoids was poor and never specified whether they were internal or external. The terminology used described the haemorrhoids by degree and position; information found supported that this related to haemorrhoids but there are no standards or local policies to support this. The recording of anaesthetics was regularly omitted or coded as unspecified when a specified type was documented, particularly Midazolam. It is a Welsh standard to record anaesthetics and a local policy to record Midazolam to Y84.8 Other anaesthetic, other specified. 3 National Clinical Coding Standards ICD-10 4 th Edition (2013) reference book XIII-1 P a g e 13

16 Hywel Dda University Health Board It is a national clinical coding standard 4 to record transthoracic echocardiograms (TTE) whenever they are performed on inpatient episodes. It further confirms that a clinical statement of echocardiogram or echo without further specification is coded to U20.1 Transthoracic echocardiogram. TTEs being omitted from the coding record across all sites made up 10 of the omitted procedures. There were a number of occasions when angiocardiography procedures were coded with Y53.4 Approach to organ under fluoroscopic control assigned in a supplementary position without the method being specified in the medical record. There was no local policy employed for this, and as such should have been coded to Y53.9 Unspecified approach to organ under image control. There were a number of occasions when Y79.3 Transluminal approach to organ through femoral artery was assigned to supplement a code for an angiocardiography. There is no standard to state that this should not be coded but the guidance in the OPCS-4.6 Instruction Manual 5 indicates that this category is only intended to be assigned for transcatheter aortic valve implantation (TAVI) procedures. 4 OPCS-4.6 Clinical Coding Instruction Manual U-15 5 OPCS-4.6 Clinical Coding Instruction Manual Y-23 P a g e 14

17 Hywel Dda University Health Board 6.4. Payment analysis Payment Pre- Payment Post- Gross financial Net Financial Number of audit audit change change episode UTAs 283, ,011 9,428 6, These figures are based on the English Payment by Results system that processes funding through the tariff attached to Healthcare Resource Groupings. This information is used purely as an indication of the impact of the clinical coding and not related to the funding that Hywel Dda University Health Board received. The data is comparative and may not be fully compliant with all requirements of the Payment by Results mechanism. P a g e 15

18 Hywel Dda University Health Board Appendix A: Detailed coding assessment Ref Record ID Diagnosis Health Board code Audit Code Diagnosis Error Type Rationale Financial implication Primary diagnoses i Cystocele N811 N814 Uterovaginal prolapse, unspecified PDI Coded from urodynamics sheet only. Other documentation stated that the patient had a uterine prolapse. 0 ii Gastroenteritis and colitis of unspecified origin A099 A080 Rotaviral enteritis PD3 Stool sample came back as rotavirus four days post discharge, which the coders would have had access to. 0 iii Left ventricular failure I501 I500 Congestive heart failure PD4 States that the patient has "biventricular failure", which trails to I iv Unspecified acute lower respiratory infection Chronic obstructive pulmonary disease with acute lower respiratory infection J22X J440 Chronic obstructive pulmonary disease with acute lower respiratory infection PDIS J SDNR The patient had COPD and a chest infection, which is linked to J44.0 and does not require the J22.X, in accordance with the national standards A p p e n d i x A.1

19 Hywel Dda University Health Board Ref Record ID Diagnosis v Chronic obstructive pulmonary disease, unspecified Health Board code Audit Code Diagnosis J449 K219 Gastro-oesophageal reflux disease without oesophagitis Error Type PDO Rationale The patient was admitted for an OGD due to reflux disease, which had not been coded. Financial implication 0 Secondary diagnoses vi I209 Angina pectoris, unspecified SDI The patient was having an angiocardiography because of worsening angina. This was not mentioned on the angiocardiography form, and the coders don't have access to notes for these investigations. 0 vii Aortic valve disorder, unspecified I359 I080 Disorders of both mitral and aortic valves SD3 Patient has aortic and mitral regurgitation, which was documented in the notes but not reflected in the coding. 0 viii Left ventricular failure I501 I518 Other ill-defined heart diseases SD4 Left ventricular failure was never confirmed, only left ventricular systolic dysfunction. The Health Board does not have a policy to code this diagnosis in such a way. 0 ix Z539 Procedure not carried out, unspecified reason SDO The patient was admitted for a direct current cardioversion, but this was cancelled A p p e n d i x A.2

20 Hywel Dda University Health Board Ref Record ID Diagnosis x Other aortic valve disorders Health Board code Audit Code Diagnosis Error Type Rationale I SDNR Aortic sclerosis was noted on echocardiogram, but this was not carried out until the next episode. Financial implication 0 xi Intentional selfpoisoning by and exposure to antiepileptic, sedativehypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified - Home X610 X619 Intentional selfpoisoning by and exposure to antiepileptic, sedativehypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified - Unspecified place ECI The medical record does not state where overdose took place. 0 xii Hypo-osmolality and hyponatraemia E871 E222 Syndrome of inappropriate secretion of antidiuretic hormone Y492 Drugs, medicaments and biological substances causing adverse effects in therapeutic use - Other and unspecified antidepressants SD3 ECO The hyponatraemia was due to SIADH, which was secondary to sertraline. 0 A p p e n d i x A.3

21 Hywel Dda University Health Board Ref Record ID Diagnosis xiii Drowning and submersion while in swimming-pool - Sports and athletics area Health Board code Audit Code Diagnosis Error Type Rationale W ECNR The external cause code had been unnecessarily repeated. Financial implication 0 Primary procedure/intervention xiv Diagnostic fibreoptic endoscopic examination of upper gastrointestinal tract - Unspecified G459 G448 Other therapeutic fibreoptic endoscopic operations on upper gastrointestinal tract - Other specified PP3 The scope was used to unblock the stent, which is a form of therapeutic procedure and should have been reflected as such in the coding. 0 xv Diagnostic fibreoptic endoscopic examination of upper gastrointestinal tract - Unspecified G459 G451 Fibreoptic endoscopic examination of upper gastrointestinal tract and biopsy of lesion of upper gastrointestinal tract PP4 It stated on the endoscopy sheet that they took a cold biopsy from duodenum, which was not reflected in the primary procedure code xvi Excision or biopsy of axillary lymph node T873 B274 Total mastectomy NEC PPIS - There is an issue with Medicode, which altered the sequence of the procedure codes into chronological order. The coder can change them back, but they had not on this occasion. Total mastectomy NEC B274 T873 Excision or biopsy of axillary lymph node A p p e n d i x A.4

22 Hywel Dda University Health Board Ref Record ID Diagnosis Health Board code Audit Code Diagnosis xvii U201 Transthoracic echocardiography Error Type PPO Rationale The patient had an echocardiogram, which must be recorded in accordance with national clinical coding standards, but had not been. Financial implication 0 xviii Direct current cardioversion X PPNR The patient was admitted for a DC cardioversion, but this was cancelled. 0 Secondary procedure/intervention xix Y829 Local anaesthetic - Unspecified SPI Anaesthetic not specified on documentation used by the coder. 0 xx Rubber band ligation of haemorrhoid xxi Approach to organ under fluoroscopic control H524 L703 Ligation of artery NEC SP3 The patient underwent a haemorrhoidal artery ligation operation (HALO) procedure, which has a national standard that must be adhered to, which had not been on this occasion. Y534 Y539 Approach to organ under image control - Unspecified SP4 Method of image control was not specified as fluoroscopic. 0 0 A p p e n d i x A.5

23 Hywel Dda University Health Board Ref Record ID Diagnosis Health Board code Audit Code Diagnosis Error Type xxii Computed tomography NEC U212 U212 Computed tomography NEC Radiology with postcontrascontrast Y973 Y973 Radiology with post- Chest NEC Z924 Y983 Radiology of three body SPIS areas (or twenty forty minutes) Radiology of three body Y983 Z924 Chest NEC areas (or twenty forty minutes) Abdomen NEC Z926 Z926 Abdomen NEC Pelvis NEC O161 O161 Pelvis NEC xxiii Y84.8 Other anaesthetic - Other specified xxiv Creation of temporary ileostomy G742 G751 Refashioning of ileostomy PP3 Closure of ileostomy G SPNR Revisional operations Y SPNR NOC SPO Rationale All of the codes for the CT scan were recorded, but there is a precise sequencing standard that states that the Y98 must follow the Y97 code. The coding of anaesthetic is a national standard, and the Health Board have a policy to record sedation with specified drugs, which had not been omitted. The ileostomy was stated to have been 'revised and 'refashioned'; the lead term refashioning is indexable and would cover the creation of a new ileostomy and the revision of the original ileostomy. Financial implication A p p e n d i x A.6

24 Appendix B: Recommendations 1. Training Issue Identified There were a number of issues identified during the audit relating to the interpretation of the information contained in the medical record and/or the national standard that relate to it. The particular areas that were routinely identified by the auditors were: Co-morbidities were regularly omitted from the coding. This related to conditions that impacted on the patient s healthcare, and regularly to classification standards. Omitted co-morbidities were the most common error type identified. Endoscopy reports were often misinterpreted, with the primary diagnosis recorded by the coder often being an incidental finding and not the reason for the investigation. In addition the adherence to national standards relating to endoscopies was not always followed. The omission of transthoracic echocardiograms when they were clearly documented in the medical record; this issue was identified at all sites; The coding of anaesthetics is a standard in Wales, and must be coded when it is documented; as well as this there is a local policy for the coding of Midazolam. These were regularly omitted. Risk Rating Medium Recommendation The Health Board should conduct a series of short training sessions over the following weeks to ensure that issues highlighted on audit are addressed with the clinical coders. This will provide a forum for coders to consolidate their understanding and ask questions to clarify the standards. This should be followed up with internal audit one to two months later on the areas addressed to ensure that these sessions have improved the quality of the clinical coding. A p p e n d i x C.1

25 2. Utilisation of in-house auditor Issue Identified The Health Board has supported the training of an in-house Clinical Coding Auditor. The requirements of maintaining an auditor registration means that a significant amount of their time needs to be spent on coding tasks. The Health Board to this point have continued to support this by providing time to carry out these tasks. The support of this role should support the continued improvement of the data quality of the coding function. Risk Rating Medium Recommendation The Health Board should continue to support the in-house Clinical Coding Auditor s utilisation. Over time this could be increased to incorporate working with directorates and clinicians to identify areas where the coding and information provided to support it could be improved. This in turn will lead to increased awareness and respect for the function and promote a general desire to support each function in producing quality information. A p p e n d i x C.2

26 3. Discuss Medicode issues with system developer Issue Identified There were a number of occasions when the auditors found errors in the sequence of procedures, which meant the most resource intensive procedure was sequenced in a secondary position. This was particularly the case with diagnostic procedures being sequenced in a primary position ahead of therapeutic. On discussion it would appear this is a known issue with the Medicode encoder, which re-sequences procedure codes into chronological order when transferred to the Myrddin Patient Administration System. The coders can alter the sequence on Myrddin but this is a waste of resource, as well as there being potential to forget to do it. Risk Rating Medium Recommendation The Health Board should discuss the issue with 3M, the suppliers of Medicode, at the earliest opportunity and ask for a patch to be written to prevent this issue from continuing. In the interim the Clinical Coding Manager should highlight this finding to the clinical coders and ask them to be vigilant in ensuring that, before finalisation, the procedure codes are sequenced in the correct position. A p p e n d i x C.3

27 4. Local policy Issue Identified There were a number of occasions when the clinical coding was coded to a more specific code than what was documented in the medical record. This indicated that the coders were aware of the method used for particular procedures but this was not supported in the record or through the use of local policies. This was particularly relevant for angiocardiography procedures that were consistently coded with a supplementary code to reflect it was carried out under fluoroscopic image guidance. It was also noted by the auditors that the quality of information provided for care of haemorrhoids was poor. The detail was often limited and used terminology that cannot be reflected in the clinical coding without the use of local policies. Risk Rating Low Recommendation The Clinical Coding Manager should discuss these and any other applicable areas with the relevant clinicians and/or directorates to ensure that local policies can be implemented, where needed, to improve the quality of the clinical coding. These local policies should be implemented as soon as possible to avoid them being flagged as errors in future audits. In addition they should have set review dates to ensure they continue to reflect current practice and be signed off as understood by all relevant clinical coders. A p p e n d i x C.4

28 5. Query the use of Y79 Issue Identified The auditors noted that Y79.3 Transluminal approach to organ through femoral artery was assigned in supplementary position following a code for an angiocardiography. There is no standard to state that this should not be coded but the guidance in the OPCS-4.6 Instruction Manual indicates that this category is only intended to be assigned for transcatheter aortic valve implantation (TAVI) procedures. Risk Rating Low Recommendation The Health Board should send a query to the Welsh Standards Service Desk to establish whether there is a requirement to assign the Y79.3 code following this procedure or whether this is superfluous to the record. The resolution will then dictate whether they should continue to assign the code in this way or to omit it in the future. A p p e n d i x C.5

29 Appendix C: Site analysis Prince Philip Hospital Primary diagnoses Number of episodes Number correct Percentage Coder Error Number Percentage PD PDO Secondary diagnoses Number of valid diagnoses Number correct Percentage Non-coder Error Number Percentage SDI A p p e n d i x C.6

30 Coder Error Number Percentage SD SD SDO SDNR 7 - Primary procedure/intervention Number of episodes Number correct Percentage Secondary procedure/intervention Number of episodes Number correct Percentage Non-coder Error Number Percentage SPI Coder Error Number Percentage SP SP SPO Glangwili General Hospital A p p e n d i x C.7

31 Primary diagnoses Number of episodes Number correct Percentage Coder Error Number Percentage PD PD PDIS PDO Secondary diagnoses Number of episodes Number correct Percentage Non-coder Error Number Percentage SDI Coder Error Number Percentage SD SDO SDNR 5 - Primary procedure/intervention A p p e n d i x C.8

32 Number of episodes Number correct Percentage Coder Error Number Percentage PP PP PPIS PPO Secondary procedure/intervention Number of episodes Number correct Percentage Coder Error Number Percentage SP SP SPO SPNR 5 - A p p e n d i x C.9

33 Withybush General Hospital Primary diagnoses Number of episodes Number correct Percentage Non-coder Error Number Percentage PDI Coder Error Number Percentage PD PDIS PDO A p p e n d i x C.10

34 Secondary diagnoses Number of episodes Number correct Percentage Non-coder Error Number Percentage SDI Coder Error Number Percentage SD SD SDO SDNR 2 - ECI ECO A p p e n d i x C.11

35 Primary procedure/intervention Number of episodes Number correct Percentage Coder Error Number Percentage PP PP PPIS PPO PPNR 1 - Secondary procedure/intervention Number of episodes Number correct Percentage Coder Error Number Percentage SP SP SPIS SPO SPNR 3 - A p p e n d i x C.12

36 Bronglais General Hospital Primary diagnoses Number of episodes Number correct Percentage Coder Error Number Percentage PDO Secondary diagnoses Number of episodes Number correct Percentage Coder Error Number Percentage SD SD SDO SDNR 4 - ECNR 3 - A p p e n d i x C.13

37 Primary procedure/intervention Number of episodes Number correct Percentage Coder Error Number Percentage PP PPO PPNR 1 - Secondary procedure/intervention Number of episodes Number correct Percentage Coder Error Number Percentage SP SPO SPNR 2 - A p p e n d i x C.14

38 Appendix D: Audit approach The audit was based on the NHS Clinical Coding Audit Methodology Version 7.0 and the Code of Best Practice for Clinical Coding Auditors. The documents provide guidance on conducting a clinical coding audit. Codes on CDS were considered accurate if they described the actual condition of the patient (and any procedures performed) as completely as possible within the constraints of the classifications used. The three dimensions of the coding accuracy are: Individual codes: are they an accurate reflection of the clinical statement? Totality of codes: do they represent all the relevant clinical details? Sequencing of codes: are the codes in the correct sequence as defined by the rules and conventions of the classification, and the mandated definition of a primary diagnosis? Coding errors were then evaluated as follows: Incorrect main diagnosis selected Incorrect three character category Incorrect fourth character category Omission of diagnosis / procedure codes Unnecessary codes Incorrect sequencing of diagnostic / procedure codes Accurate coded information is essential for many areas of accountability in the NHS. Information derived from clinical coding is used in many areas at secondary and primary care, strategic health authority and national level to analyse performance and levels of achievement, to support the government's national initiatives to improve service quality and deliverance through Payment by Results, clinical indicators and clinical governance. However, all information for coding purposes is derived from the information provided by the clinical staff responsible for the patient. It is therefore essential that all information recorded in the patient s medical record be documented clearly, accurately and completely. A p p e n d i x C.15

39 The audit did not concentrate solely on the accuracy of the coding, but also on other factors influencing the coding process. Without studying the wider picture of how information is created for coding purposes, one cannot expect to attain a realistic picture of the factors that determine the accuracy of coding. Other areas studied during the audit included: Documentation issues: Document incomplete Documentation inconsistent, unclear Terminology unclear Information regarding the episode not available in the clinical records Lack of clear procedures for coding and abstraction Lack of procedures for reviewing clinical records Coded to consultant specification (resulting in a contravention of a coding rule/convention or standard) The error keys used were based on those outlined in NHS Clinical Coding Audit Methodology Version 7.0 (Appendix D). The auditors documented any discrepancies found using the appropriate audit worksheets. A first draft of the audit report including findings, conclusions and recommendations of the audit was submitted to the Health Board for review. The auditors also checked the accuracy of a subset of key data items for Admitted Patient Care. These were: Start date (episode) End date (episode) Secondary diagnosis (ICD) Primary procedure (OPCS) Procedure date (primary) A p p e n d i x C.16

40 Appendix E: Glossary of coding error codes Unsafe to Audit Error Key UTA UNSAFE TO AUDIT The auditor is unable to audit the coded clinical data against the source documentation. For example, there is insufficient or no information regarding the episode in the auditor s source documentation. Primary Diagnosis Error Key Coder Error PD3 PRIMARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL The primary diagnosis code has been allocated to an incorrect three character. PD4 PRIMARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL The primary diagnosis code has been allocated to an incorrect fourth character. PD5 PRIMARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL The primary diagnosis code has been allocated to an incorrect fifth character. PDIS PRIMARY DIAGNOSIS INCORRECTLY SEQUENCED The primary diagnosis code recorded by the auditor has not been sequenced by the coder as the primary diagnosis. PDO PRIMARY DIAGNOSIS OMITTED The primary diagnosis recorded by the auditor has not been recorded by the coder in any diagnosis field. Non-Coder Error PDI PDD INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING Information available to the auditors was not available at the time of coding. This is where information regarding the episode became available after the episode was coded. This error key is not to be used if the information was not accessed by the clinical coder at the point of coding, for example, with histopathology reports. This error key would also be assigned by the auditor when the source documentation used at the time of coding did not contain all pertinent information required for accurate and complete coding and the coder did not have access to this information, for example, coding from pro-forma with no access to the casenotes. PRIMARY DIAGNOSIS DOCUMENTATION ISSUE The auditor is unable to code the clinical data from the source documentation and compare against that of the Health Board s due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct The source documentation is illegible. A p p e n d i x D.1

41 PDM PRIMARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG. PDC PRIMARY DIAGNOSIS CODED TO CONSULTANT SPECIFICATION There is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures a diagnosis. For example, by unbundling diagnoses or procedures into component parts. PDSC PRIMARY DIAGNOSIS INCORRECT DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses the primary diagnosis code is technically incorrect at some level, omitted or sequenced incorrectly. Secondary Diagnosis Error Key Coder Error SD3 SECONDARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL The secondary diagnosis code has been allocated to an incorrect three character. SD4 SECONDARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL The secondary diagnosis code has been allocated to an incorrect fourth character. SD5 SECONDARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL The secondary diagnosis code has been allocated to an incorrect fifth character. SDNR SECONDARY DIAGNOSIS NOT RELEVANT The secondary diagnosis recorded by the coder is not relevant to the episode of care. SDO SECONDARY DIAGNOSIS OMITTED The secondary diagnosis has been recorded by the auditor as relevant but is missing from the Organisation s recorded episode. SDIS SECONDARY DIAGNOSIS INCORRECT SEQUENCING The sequence of the secondary diagnosis codes contravenes national standards. This error key can only be assigned for error in the following national standards: 1. Outcome of delivery (Z37 and Z38 if not well baby) 2. Asterisk codes must be preceded by a dagger code 3. Specific coding conventions in ICD-10 i.e. use additional code 4. Extent of body surface in burns (T31, T32). ECI EXTERNAL CAUSE CODE INCORRECT The external cause code recorded by the Organisation is incorrect at any character level. ECO EXTERNAL CAUSE CODE OMITTED The external cause code has been omitted from the Organisation s recorded episode. ECNR EXTERNAL CAUSE CODE NOT RELEVANT The external cause code recorded by the coder is not relevant to the episode of care. Non-Coder Error A p p e n d i x D.2

42 SDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING Information available to the auditors was not available at the time of coding. This is where information regarding the episode became available after the episode was coded. This error key is not to be used if the information was not accessed by the clinical coder at the point of coding, for example, with histopathology reports. This error key would also be assigned by the auditor when the source documentation used at the time of coding did not contain all pertinent information required for accurate and complete coding and the coder did not have access to this information, for example, coding from pro-forma with no access to the casenotes. SDD SECONDARY DIAGNOSIS DOCUMENTATION ISSUE The auditor is unable to code the clinical data from the source documentation and compare against that of the Health Board s due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct The source documentation is illegible. SDM SECONDARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG. SDC SECONDARY DIAGNOSIS CODED TO CONSULTANT SPECIFICATION There is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures a diagnosis. For example, by unbundling diagnoses or procedures into component parts. SDSC SECONDARY DIAGNOSIS INCORRECT DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses the secondary diagnosis code is technically incorrect at some level, omitted or sequenced incorrectly. Primary Procedure Error Key Coder Error PP3 PP4 PPIS PPO PRIMARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL The primary procedure code has been allocated to an incorrect three character. PRIMARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL The primary procedure code has been allocated to an incorrect fourth character. PRIMARY PROCEDURE INCORRECTLY SEQUENCED The primary procedure code recorded by the auditor has not been sequenced by the coder as the primary procedure. PRIMARY PROCEDURE OMITTED The primary procedure recorded by the auditor has not been recorded by the coder in any procedure field. A p p e n d i x D.3

43 PPNR PRIMARY PROCEDURE NOT RELEVANT The primary procedure recorded by the coder is not relevant to the episode of care. Non-Coder Error PPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING Information available to the auditors was not available at the time of coding. This is where information regarding the episode became available after the episode was coded. This error key is not to be used if the information was not accessed by the clinical coder at the point of coding, for example, with histopathology reports. This error key would also be assigned by the auditor when the source documentation used at the time of coding did not contain all pertinent information required for accurate and complete coding and the coder did not have access to this information, for example, coding from pro-forma with no access to the casenotes. PPD PRIMARY PROCEDURE DOCUMENTATION ISSUE The auditor is unable to code the clinical data from the source documentation and compare against that of the Health Board s due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct The source documentation is illegible. PPM PRIMARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG. PPC PRIMARY PROCEDURE CODED TO CONSULTANT SPECIFICATION There is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures a diagnosis. For example, by unbundling diagnoses or procedures into component parts. PPSC PRIMARY PROCEDURE INCORRECT DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses the primary procedure code is technically incorrect at some level, omitted or sequenced incorrectly. Secondary Procedure Error Key Coder Error SP3 SP4 SPIS SECONDARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL The secondary procedure code has been allocated to an incorrect three character. SECONDARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL The secondary procedure code has been allocated to an incorrect fourth character. SECONDARY PROCEDURE INCORRECTLY SEQUENCED The Organisation has not sequenced the procedure coding according to the rules and conventions of the classification. A p p e n d i x D.4

44 SPO SECONDARY PROCEDURE OMITTED The secondary procedure recorded by the auditor as relevant but is missing from the Organisation s recorded episode. SPNR SECONDARY PROCEDURE NOT RELEVANT The secondary procedure recorded by the coder is not relevant to the episode of care. Non-Coder Error SPI SPD SPM SPC SPSC INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING Information available to the auditors was not available at the time of coding. This is where information regarding the episode became available after the episode was coded. This error key is not to be used if the information was not accessed by the clinical coder at the point of coding, for example, with histopathology reports. This error key would also be assigned by the auditor when the source documentation used at the time of coding did not contain all pertinent information required for accurate and complete coding and the coder did not have access to this information, for example, coding from pro-forma with no access to the casenotes. SECONDARY PROCEDURE DOCUMENTATION ISSUE The auditor is unable to code the clinical data from the source documentation and compare against that of the Health Board s due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct. The source documentation is illegible. SECONDARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG. SECONDARY PROCEDURE CODED TO CONSULTANT SPECIFICATION There is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures a diagnosis. For example, by unbundling diagnoses or procedures into component parts. SECONDARY PROCEDURE INCORRECT DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses the secondary procedure code is technically incorrect at some level, omitted or sequenced incorrectly. A p p e n d i x D.5