Clinical Coding Audit Report

Transcription

1 ` Clinical Coding Audit Report Royal Glamorgan Hospital Cwm Taf University Health Board Karen Windsor ACC, Cwm Taf University Health Board Richard Burdon ACC, NHS Wales Informatics Service

2 CONTENTS Executive Summary Introduction Aims Objectives Background Methodology Findings Conclusions Recommendations Page 2 of 37

3 Executive Summary 1.1 Introduction This audit represents part of an ongoing series of clinical coding accuracy audit reports, produced as part of the NHS Wales Informatics Services national clinical coding audit programme. This programme was established following the completion of an initial all-wales audit of clinical coding accuracy that was undertaken in collaboration with Welsh Audit Office (WAO) in 2013/ The programme intends to identify areas of improvement or non-improvement following the recommendations given in those (and subsequent) audits This programme is being taken forward by the Informatics Service s Clinical Classifications Team and will ensure a continual ongoing programme of clinical coding accuracy audit across all Welsh Health Boards and NHS Trusts This report outlines the findings and recommendations of the Informatics Service s Clinical Classifications Team audit of clinical coding accuracy at the Royal Glamorgan Hospital. 1.2 Methodology The sample audited was 150 Finished Consultant Episodes (FCEs), which were randomly generated from the activity data held within the Patient Episode Database for Wales (PEDW). Only FCEs from the specialties of General Medicine, General Surgery and Trauma & Orthopaedics were audited. The period audited covered episodes with an end date of 1 st April to 31 st July inclusive 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) Attention was also paid to the patient case notes being used by the coders and auditors in order to assess their impact on the assignment of codes. 1.3 Findings The coding audit contained a number of significant errors. However, even though the accuracy for the primary diagnosis (i.e. the main condition treated) was below the expected 90%, it represents a significant improvement from the 70.97% which was achieved in the previous audit (see Appendix 2). Below is a breakdown of the error rates: Code Type Primary Diagnosis Secondary Diagnosis Primary Procedure Secondary Procedure Total Number of Codes Reviewed Total Number of Correct Codes % % % % Percentage Correct Page 3 of 37

4 1.3.2 The largest number of secondary coding errors found in the above categories were due to the conditions documented in the case notes not being recorded by the clinical coding staff. 1.4 Case Note Findings The case notes used in the audit were in generally in a poor state and very difficult to extract the relevant information from for a number of reasons Missing or misfiled documentation Contradictory and changing diagnoses record by clinical staff Bulky case notes which were overfilled with numerous loose documents 1.5 Conclusions The coding accuracy for the primary diagnosis has improved from 70.97% in the previous audit to 88.70%; this is in large part due to the system of coding the case notes on the wards onto proformas having been abolished. At the time of auditing all episodes (with the exception of endoscopies) were now being coded from the case notes (within the clinical coding department) straight on to the PAS (Myrddin) via the encoder (Medicode), with additional information being available to the coding staff on electronic systems (Welsh Clinical Portal, Theatres, Maternity and Intensive Care systems) The coding accuracy of secondary diagnoses fell from 64.60% in the previous audit to 63%. Around 30% of these errors were due to co-morbidities being omitted by the clinical coding staff despite being recorded in the case notes. The coding staff in the Royal Glamorgan Hospital are all up to date with their mandatory training and generally demonstrate a sound grasp of national clinical coding rules and standards. The lack of staff with the ACC qualification remains a concern, since it prevents the organisation from being assured that its coding staff are coding to a recognised national standard and it makes it impossible to ascribe a baseline level of expertise to the clinical coders in the Royal Glamorgan Hospital. Endoscopy (sigmoidoscopy/colonoscopy) and bronchoscopy sheets provide detailed information for coding the procedure undertaken. However, they do not state a definitive diagnosis, which may differ from the documented reason for admission and may not contain any of the patient s co-morbidities The auditors experienced difficulties due the poor condition of the case notes, which exacerbates the problems experienced by the coding staff when trying to code to rigid timeliness and accuracy targets. A lack of regular clinical coding audits and assessment has lead to situation where individual coding staff (especially band 3 trainees) are not receiving well timed and comprehensive feedback on their coding quality. Page 4 of 37

5 The auditors noted that there has been an effort to enhance the clinical involvement with the coding department; through initiatives such as the clinical coding bookmark application and regular attendance of the clinical coding team at the SHO s induction days. However, the clinical coding department is still yet to establish a programme whereby clinicians routinely validate their coded activity data. 1.6 Recommendations The clinical coding staff must be made aware of the importance of identifying and assigning the codes for all co-morbidities and management must ensure that they are given adequate time and resources to allow them to extract all the relevant data, especially when coding complex and long stay admissions. Clinical coding staff should continue to attend all mandatory training sessions and specialty workshops in order to maintain their competency. Continual reviews of individual s workloads and activity should be conducted at regular intervals by the coding management team. To ensure that any targets allocated to coders take into account any extra duties (i.e. mentoring or attendance at meetings) that the coder might be undertaking as part of their personal development and the complexity of the admissions they are coding. The clinical coding auditor/supervisor along with the clinical coding manager should immediately put into action a programme to regularly audit the accuracy of individual coders. Particularly attention should be given to the auditing of the episodes coded by the band 3 trainee coders. The results of these audits should be fed back to the coding staff as part of their regular professional development reviews, beginning with the next round of reviews. Lead consultants for each speciality should be engaged to initiate a coding validation program in order to increase the quality of the coded data in terms of standards and optimise the coding for the benefits of the organisations and clinical departments. The auditors have noted that working groups have been initiated to improve the condition and quality of the case notes this is a work in progress group, results will be verified during the current financial year. The senior coding team should commence a program to substantiate the outcome of each incident report to ensure that they are acted upon. The clinical coding manager should engage with the clinician responsible for the endoscopy reports, to ensure that a definitive diagnosis and a comprehensive list of co-morbidities are recorded on the report, if coding from the full case notes is not feasible A further, large scale audit of the clinical coded data in the Royal Glamorgan Hospital should be carried out to validate the findings of this audit and to further clarify any areas that need improvement for the future development of the department and individuals. Page 5 of 37

6 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, accurate-coded APC data are an essential pre-requisite for numerous current and emerging decision support processes. 2.2 Welsh UHB/LHBs and Velindre NHS Trust are mandated to clinically code the finished consultant episodes (FCEs) for every patient admitted to a Welsh NHS hospital. 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 UHB/LHBs and Velindre Trust are currently monitored against two national performance measures of clinical coding completeness. These are: 95% of all FCEs are clinically coded within 3 months of the episode end date; 98% of all FCEs are clinically coded for any given rolling 12 month period. 2.4 There are currently no national performance indicators or measures for clinical coding accuracy. 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 Welsh Government performance indicators and measures); Providing the basis of the Risk Adjusted Mortality Index (RAMI), a current WG priority area. 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; Financial costing and resource utilisation mapping; Ad hoc requests (be they Ministerial, AQs, media/public and so on); 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); Clinical coding data is central to a range of national information initiatives, such as the annual financial costing process and patient-level costing 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. 2.6 It is a therefore a requirement that clinical coded data are accurate, consistent, complete and coded in a timely fashion. Page 6 of 37

7 2.7 Clinical coding audit is currently the only means by which it is possible to assure the accuracy of clinical coded data. 2.8 Support from NWIS was requested by WAO, as it is recognised that audits of clinical coding accuracy requires specific clinical coding expertise that is not present within WAO. 2.9 Cwm Taf UHB was the pilot organisation for the 2013/14 WAO clinical coding audits. It was agreed that following the completion of the WAO audits, the NHS Wales Informatics Service s clinical classifications team would return to carry out a follow-up audit to identify any areas of improvement and departmental change, as a result of the recommendations in the original audit This audit represents part of an ongoing cycle of clinical coding accuracy audit reports, produced as part of the NHS Wales Informatics Services national clinical coding audit programme. This programme is being taken forward by the Informatics Service Clinical Classifications Team and will ensure a continual schedule of clinical coding accuracy audits across all Welsh Health Boards and NHS Trusts This report outlines the findings and recommendations of the Clinical Classifications Team s follow-up audit of clinical coding accuracy at the Royal Glamorgan Hospital. The audit was carried out on five days between 22 nd January and 25 th February 2015 and was undertaken by two Accredited Clinical Coding Auditors. 3 Aims 3.1 The aim of this audit was to assess the accuracy of the clinically coded data produced by Royal Glamorgan Hospital 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 Royal Glamorgan Hospital and Cwm Taf University Health Board (UHB), 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 Royal Glamorgan Hospital. 3.4 This audit was commissioned to validate the findings of the previous audit in 2014 and to further clarify areas for improvement for the clinical coding department following the rescinding of the policy of coding on the wards. 4 Objectives 4.1 The objectives for the audit were: To assess the clinical coding data against national clinical coding standards; To identify and report areas of good and bad practice; To review and assess the accuracy of the source documentation used for clinical coding; Page 7 of 37

8 To assess the level of clinical involvement with the coding department and to what degree this impacts on the coding process and coding accuracy; To make recommendations designed to support future improve in the accuracy of clinically coded data within the hospital; Highlight training issues within the department. To assess areas of improvement or non-improvement following recommends of previous audit in Background 5.1 The Royal Glamorgan Hospital is one of two hospitals within the Cwm Taf UHB at which clinical coding staff are based, the other being Prince Charles Hospital. 5.2 Demographics & Staffing Cwm Taf UHB generated a total of 97,368 Finished Consultant Episodes (FCEs) in the 2013/14 financial year. Of these, Royal Glamorgan Hospital generated 52,738 FCEs Clinical coding staff at Royal Glamorgan Hospital assign codes to episodes that take place in both acute and community hospital sites within the Health Board Cwm Taf UHB achieved 97.5% completeness for clinical coding as of the submission date at the end of June This is a significant improvement on the position over the previous year, where the 98% target for clinical coding completeness was not met There is a total establishment of 3.75 WTE band 3 trainee coders and WTE band 4 coders across the whole of Cwm Taf UHB. In addition to this core complement of staff, there is one full time Band 5 Supervisor/Auditor, based at Prince Charles Hospital, and one band 6 Health Board Clinical Coding Manager (who retains full responsibility for all the clinical coding services provided across the UHB), who is based in the Royal Glamorgan Hospital. Whole Time Equivalents (WTE) by Site Band Prince Charles Royal Glamorgan Total During the period being audited there were no WTE vacancies within the Royal Glamorgan coding department Coders range in experience in the coding department from 1 year to 22 years as coders The Royal Glamorgan Hospital has coders based in a centralised office, with separate area for the storage of case notes, to keep disturbances to a minimum During the period of time examined by this audit the coding department had no significant backlog of uncoded episodes and were comfortably meeting the clinical Page 8 of 37

9 5.3 Workloads coding monthly completeness target of 95%. Figures available at the time of the audit shows that for the current financial year there was a backlog of around 9,500 FCEs, which the UHB was reducing every month through overtime and increased productivity, through the weekly monitoring of staff coding targets and decreased departmental sickness Cwm Taf UHB clinical coding staff are expected to code between 6,000 and 6,500 FCEs per year. This is a locally set target based on a full time band 4 coder working 37.5 hours per week. For part time band 4 clinical coders, this amount would be reduced pro rata. Band 3 trainees do not have a target, whilst they are training and studying for their ACC Due to efforts to totally clear the backlog and to meet the coding completeness targets overtime is offered to coders in both Royal Glamorgan and Prince Charles hospitals. This can be taken on the weekend by full time staff, or on the weekend or non-working week days by part time staff. The UHB is hoping to meet the 98% coding completeness within a rolling 12 months target mid May Overtime has been financed and approved until this target has been meet The figures available for workloads in Royal Glamorgan Hospital are for the period from April 2014 to Dec This shows the number of FCEs each WTE coder completed in this period. An estimated figure for a 12 month period was extrapolated (using the formula x 9*12, where x is the number coded in 9 months). The table below shows productivity information for each member of the coding department in the Royal Glamorgan Hospital. Hours worke d per week 5.4 Training Expected FCE per year (pro-rata) FCE coded: April 2014 Dec 2014 Estimated Yearly Total Notes ,000 6,500 7,125 9,500 Inc. Overtime ,000 6,500 6,813 9,084 Inc. Overtime ,000 6,500 6,717 8,956 Inc. Overtime 30 4,789 5,195 4,215 5, ,000 6,500 4,238 5, ,789 5,195 2,715 3, ,953 3,203 3,282 4, ,789 5, Retired 18 th April ,916 3,888 No Target band ,923 5,230 No Target band No Target band ,256 3,008 No Target band 3 Total 41,330 44,788 45,004 59, None of the clinical coding staff at the Royal Glamorgan Hospital currently hold the ACC qualification. However, one of the band 3 staff members from the Royal Page 9 of 37

10 Glamorgan Hospital has recently sat the examinations, but did not pass and another is due to sit the examinations in March All the coders both bands 3 and 4 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 There is currently an NCS approved Clinical Coding Auditor within the UHB but no Trainer. All the department s training needs are currently met by D&A Consulting; a commercial company supplying clinical coding training who provides all training services to NHS Wales via a national training contract agreed with NHS Wales Informatics Service. 5.5 Assignment of codes Coding is carried out using the 3M Medicode encoder system linked to the Myrddin Patient Administration System (PAS), which is used throughout the UHB. Codes are assigned to episodes using both the ICD-10 4th Edition and OPCS 4.7 classifications Medicode has a clinical coding validation function, and the coding manager runs validation reports to identify any basic errors in codes that have been assigned The primary source documentation used by the coders in most cases are the written patient case notes, together with typed discharge summaries when they are available. Use is also made of various electronic systems to supply supporting clinical information, such as histopathology reports, operation sheets, scanned documents, discharge letters and the results of CT and MRI scans. However, patients are admitted for endoscopic procedures are coded only from an endoscopy procedure sheet The case notes are brought into the coding office by the case note retrieval staff from the ward, medical records library and medical secretaries around the hospital. All episodes are coded and entered onto the encoder by the original coder at the time of coding. This is a change from the process at the time the previous audit was carried out, as then the coders were coding on the ward and making notes on the details of the episode from the case notes (without the aid of their classifications books.). Once this was completed for all the required episodes the process required that they returned to the clinical coding department and assigned the relevant codes from their notes. However, these episodes were not always coded immediately; instead 5.6 Previous Audits and Recommendations The last external audit was carried out in 2014 by Richard Burdon ACC and Helen Dennis ACC from NHS Wales Informatics Service, they presented a formal audit report to the UHB and a copy was also sent to the Welsh Audit Office and the Welsh Assembly, which recommended that: Clinical coding staff should continue to attend regular training sessions in order to maintain their skills. Reviews of workloads should be conducted by the coding manager to ensure that coders are coding within the recommended number of episodes Page 10 of 37

11 Clinical coding staff at the Royal Glamorgan should only code using the full medical case note in all instances and the practice of coding from only the endoscopy sheet should cease immediately The coding manager and supervisor should arrange for regular spot check audits of coded data to be brought into practice Clinical coding staff should be made aware of the importance of identifying and assigning codes for co-morbidities and must be given time when coding to properly extract data from the case notes. Cwm Taf UHB should immediately begin to support and fund clinical coders to sit the National Clinical Coding Qualification. As per the per recommendations from the previous clinical coding audit, work must continue to ensure that staff within 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 risks are being highlighted. Regular audits of each coder s work should be carried out and the results fed back to them as part of their professional development reviews, beginning with the next available review. Lead clinicians within each speciality coded would be engaged in order to begin a program of clinician validation of coded data. The coding manager and supervisor should discuss with the appropriate departments the possibility of coders attending department meetings as a link between the coding department and clinical areas. A further, larger scale audit of clinically coded data in the Royal Glamorgan Hospital should be carried out to validate the finding of this audit and to further clarify areas for improvement for the clinical coding department following rescinding of the policy of coding on the wards The approved auditor for the UHB has recently passed the HICIC approved auditor s course, and is currently working with the Clinical Coding Manager and the Performance Manager to create a Clinical Coding Audit programme for the UHB The coding manager regularly runs a validation report to identify basic errors in the coded data, and has been closely working with clinicians to validate their speciality s data to ensure the accuracy of the clinical coded data. 6 Methodology 6.1 A pre-audit questionnaire regarding details of the organisation of clinical coding services in the LHB was completed by the Clinical Coding Manager. Page 11 of 37

12 6.2 A list of 450 FCEs, drawn from three specialties, was randomly generated from the Patient Episode Database for Wales (PEDW) the national database of APC ds activity data. PEDW is managed and maintained by NWIS. 6.3 The planned number of episodes audited was 50 from each of the 3 specialties below: General Medicine General Surgery Trauma and Orthopaedic. 6.4 The episodes audited were limited to those with an episode end date of 31 st April st July 2014 inclusive. 6.5 Staff at Royal Glamorgan Hospital were required to provide the auditors with access to the written case note records associated with the requested FCEs. 6.6 The clinical coding record for each episode was generated from the hospital s clinical coding encoder software and a copy attached to the relevant set of case notes. 6.7 The auditors then assessed the locally coded data against the National Clinical Coding Standards and the Welsh Clinical Coding Standards (see Appendix 1) using ICD-10 and OPCS 4.6 classifications. 6.8 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). 6.9 Any errors were assigned to an Error Type (see Appendix 4), which specified the exact nature of the error. This information was then tabulated to calculate the statistical information required (see Appendix 3) 6.10 The errors are of two general types non-coder errors and coder errors. Non-coder errors are those errors identified as being due to a factor external to the individual coder, such as an encoder system which automatically re-sequences codes, or a local coding policy which instructs the coder to assign codes in a way which contravenes national standards. Coder errors are errors in the coding made by the coder themselves For statistical reasons and due to the judgemental nature of a code being relevant to an episode, those error types where coding staff have assigned more codes than the auditor deems relevant (i.e. overcoding ) are not counted as errors when calculating the error percentages. However, the numbers of these errors are reported and examples given for information and training purposes An analysis of the errors is given in Appendix The recommended minimum percentage of correct codes are: 90% for Primary Diagnosis and Primary Procedure Page 12 of 37

13 80% for Secondary Diagnosis and Secondary Procedures The Accredited Clinical Coding (ACC) exam also stipulates a minimum requirement of 90% accuracy for all clinical coding staff sitting the National Clinical Coding Qualification (NCCQ) exam. Furthermore, the above targets are consistent with the requirements set out in the NHS England Information Governance Toolkit requirement 505 (attainment level 2) and audits of coded data carried out by NCS auditors on English Coders Case notes which did not contain the episode to be audited were marked as Unsafe to Audit (UTA) and removed from the sample and replaced A total of 150 episodes were examined. 7 Findings 7.1 The percentages of correctly assigned codes are given below: Code Type Total Number of Total Number of Percentage Correct Codes correct codes Primary Diagnosis % Secondary Diagnosis % Primary Procedure % Secondary Procedure % The percentage of codes that were correct was below the recommended level in all 4 areas. However, since the last audit in 2014 the coding accuracy for the Primary Diagnosis has risen by 17.73% from 70.97%. When analysing the above figures, it should be taken into consideration that 6 of the primary procedure errors and 43 of the secondary procedure errors were due to diagnostic scans being incorrectly coded or omitted. And due to the structure of the coding for diagnostic scans each scan omitted can cause several secondary procedure errors. 7.2 When looked at by specialty, the percentage of correct codes is: Code Type Percent Correct in Percent Correct in Percent Correct in General Surgery General Medicine Trauma & Orthopaedics Primary Diagnosis 92.00% 86.00% 88.00% Secondary Diagnosis 70.12% 57.35% 82.07% Primary Procedure 67.74% 90.00% 70.73% Secondary Procedure 87.50% 82.75% 64.86% The graph below illustrates how many FCEs from each of the 3 specialities were without any coding errors (green) Page 13 of 37

14 No. of patient records Clinical Coding Audit Royal Glamorgan Hospital 50 Clinical Audit results (data period May to July 2014) General Medicine General Surgery Orthopaedics UTA Incorrect Unsafe to Audit Correct It should be noted that of the 150 episodes examined 78 (52.00%) contained no errors in any position. A breakdown of the error types assigned is given below. 7.3 Unsafe to Audit (UTA) There were three episodes which were marked as UTA (0.19%) of the total number of sets of case notes looked at). As per the methodology described above, they were removed from the audit and replaced. All three of the insufficient information to audit episodes were marked as such due to the case notes containing no information of any kind regarding the episode to be audited. 7.4 Primary Diagnosis Codes The primary diagnosis was correct in 88.70% of the episodes audited (133 of the 150 primary diagnoses). These were broken by specialty as follows:- General Surgery primary diagnosis correct 92.00% (46 out of the total of 50) General Medicine primary diagnosis correct 86.00% (43 out of the total of 50) Trauma and Orthopaedic primary diagnosis correct 88.00% (44 out of the total of 50) A breakdown of the errors in primary diagnoses by their associated error types is given below (see Appendix 4 for a detailed explanation of the error keys): Error Type Number of Errors Percentage of FCEs with Error PD % PD % PDIS % PDI % PDD % Page 14 of 37

15 7.4.1 Primary Diagnosis Incorrect at 3 rd Character Level (PD3) There were 7 primary diagnosis codes (4.66%) incorrect at 3 rd character level. J15.2 Pneumonia due to staphylococcus J18.1 Lobar pneumonia, unspecified On this admission current pneumonia only diagnosed as consolidation (from X-ray), no microbiology results were available for this episode to show staphylococcus pneumonia Primary Diagnosis Incorrect at 4th Character Level (PD4) There were 4 primary diagnosis codes (2.66%) incorrect at 4 th character level. R10.4 Other and unspecified abdominal pain R10.3 Pain localized to other parts of the lower abdomen The clinician made a diagnosis of RIF (right iliac fossa) pain but the coder assigned the code for abdominal pain unspecified site. National Clinical Coding Standards ICD-10 4 th Edition page XVIII-6 states R10.3 is the code used to identify RIF pain and LIF (left iliac fossa) pain Primary Diagnosis Incorrectly Sequenced (PDIS) There were 4 primary diagnosis codes (2.66%) which were incorrectly sequenced. R33 Retention of urine C61 Malignant neoplasm of prostate C61 Malignant neoplasm of prostate M8140/3 Adenocarcinoma NOS M8140/3 Adenocarcinoma NOS R33 Retention of urine The clinical information states that the patient was admitted for treatment of their urinary retention that was due to their prostate cancer. National Clinical Coding Standards ICD-10 4 th Edition page XVIII-11 states Retention of urine (R33.X) must be used as an additional code when the cause of retention is known Information available at the time of audit not available at the time of coding (PDI) There was one primary diagnosis code (0.66%) incorrect due to information being available to the auditors that was not available at the time of coding. R07.4 Chest pain, unspecified I21.9 Myocardial infarction (acute) NOS Page 15 of 37

16 The diagnosis of NSTEMI (for which the correct code assignment is I21.9) which was documented on the patient s discharge letter, was not available to the coding staff at the time of coding Primary Diagnosis Documentation Issue (PDD) There was one primary diagnosis code (0.66%) incorrect due to documentation issues. S82.80 Fracture of other parts of the lower leg (closed) S82.60 Fracture of lateral malleolus (closed) This error was due to very poor documentation. At the beginning and end of the patient s admission the clinician diagnosed a Weber C fracture involving the lateral malleolus. However, during the admission the fracture was described as a Weber B fracture and different areas of the malleolus were mentioned. 7.5 Secondary Diagnosis Codes Including External Cause and Morphology Codes The secondary diagnoses codes were 62.07% correct (198 out of the total 319 secondary diagnoses). These were broken down by specialty as follows: General Surgery secondary diagnosis correct 70.12% (54 out of the total of 77) General Medicine secondary diagnosis correct 57.35% (58 out of the total of136) Trauma and Orthopaedic secondary diagnosis correct 82.07% (87 out of the total of 106) A breakdown of the errors by their associated error types is given below (see Appendix 4 for detailed explanation of error keys): Error Key Number of Errors Percentage of Secondary Diag with Error SD % SD % SDNR % SDO % SDIS % ECI % ECO % ECNR % SDI % EC % Page 16 of 37

17 7.5.1 Secondary Diagnosis Incorrect at 3 rd Character Level (SD3) There were 5 secondary diagnoses (1.56%) incorrect at 3 rd character level. D50.9 Iron deficiency anaemia, unspecified D64.9 Anaemia, unspecified A co-morbidity of anaemia was recorded during the patient s admissions. However, no reference was made to it being iron deficiency anaemia by the responsible clinician during this admission Secondary Diagnosis Incorrect at 4 th Character Level (SD4) There were 6 secondary diagnoses (1.88%) incorrect at 4 th character level. Z86.7 Personal history of diseases of the circulatory system Z86.6 Personal history of diseases of the nervous system and sense organs It was stated in the patient s background documentation was a history of a transient cerebral ischaemic attack, which is a coded as a personal history of neurological disease and not as a personal history of a circulatory disease Secondary Diagnosis Not Relevant (SDNR) There were 41 secondary diagnoses (12.85%) assigned which were not relevant. R33 Retention of urine R33 Retention of urine I73.0 Reynaud syndrome I73.0 Reynaud syndrome D58.9 Hereditary haemolytic anaemia, unspecified During this admission there was no mention of hereditary haemolytic anaemia however it was mentioned in previous admissions Secondary Diagnosis Omitted (SDO) There were 98 secondary diagnoses (30.72%) omitted. R10.4 Other and unspecified abdominal pain R10.4 Other and unspecified abdominal pain G40.9 Epilepsy, unspecified J45.9 Asthma, unspecified I10.X Essential (primary) hypertension E78.0 Pure hypercholesterolaemia F32.9 Depressive episode, unspecified On this patient s admission a total of 5 co-morbidities were omitted, despite being clearly documented by the responsible clinician on the patient s admission sheet. Page 17 of 37

18 7.5.5 Secondary Diagnosis Incorrect Sequencing (SDIS) There were 2 secondary diagnoses (0.62%) incorrectly sequenced. J15.4 Pneumonia due to staphylococcus J15.4 Pneumonia due to staphylococcus U80.8 Resistant ot other penicillin-related U80.8 Resistant ot other penicillin-related antibiotics antibiotics J90.X Pleural effusion, not elsewhere classified J44.9 Chronic obstructive pulmonary disease, unspecified J44.9 Chronic obstructive pulmonary disease, unspecified J90.X Pleural effusion, not elsewhere classified The patient s medical record documented that they had staphylococcal pneumonia as well as COPD. National clinical coding standard DCS.X.5: COAD/COPD, chest infection and asthma with associated conditions requires the COPD to be coded immediately following the code identifying the pneumonia External Cause Code Incorrect (ECI) There were 4 incorrect external cause codes assigned (1.25%). S42.20 Fracture of upper end of humerus S42.20 Fracture of upper end of humerus closed closed W19.0 Unspecified fall at home W01.0 Fall on same level from slipping, tripping and stumbling It was documented in the nursing notes that the patient tripped over their own feet at home so the external cause code W01.0 should have been used External Cause Code Omitted (ECO) There were 4 external cause codes omitted (1.25%). I46.0 Cardiac arrest with successful T17.2 Foreign body in pharynx resuscitation R09.0 Asphyxia W79.1 Inhalation and ingestion of food causing obstruction of respiratory tract - residential institution I46.0 Cardiac arrest with successful resuscitation The clinician stated on this patient s admission that the cardiac arrest was secondary to the hypoxia due to choking on food. The coder did not assign the necessary external cause code to identify the asphyxia was due to the patient choking on food. Page 18 of 37

19 7.5.8 External Cause Code Not Relevant (ECNR) There was 1 external cause code assigned (0.31%) which was not relevant. S83.5 Sprain and strain involving (anterior) (posterior) cruciate ligament of knee W17.9 Other fall from one level to another unspecified place M23.21 Derangement of meniscus due to old tear or injury medial collateral ligament or Other and unspecified medial meniscus The patient was admitted to correct an old injury to the medial meniscus as diagnosed by the responsible clinician. National Clinical Coding Standards ICD-10 4 th Edition page XIII-11 states codes in Chapter XIII describe chronic (old) conditions only. Had the tear been a current injury, a code form Chapter XIX Injury, poisoning and certain other consequences of external causes would have been assigned instead. A joint injury where the inflammation has resolved, but then the inflammation recurs, is an old/recurrent injury and should be assigned a code from Chapter XIII Information available at the time of audit not available at the time of coding (SDI) There was 1 secondary diagnosis errors (0.31%) due to information being available to the auditors that was not available at the time of coding. R03.0 Elevated blood-pressure reading, without diagnosis of hypertension I10.X Essential (primary) hypertension A diagnosis of hypertension was made on the discharge summary but this was not available to the coding staff at the time of coding. 7.6 Primary Procedure Codes There were 91 primary procedure codes assigned. The primary procedure was correct in 78.02% of the episodes audited (71 of the 91 primary procedures). These were broken down by specialty as follows: General Surgery primary procedures correct 80.00% (24 out of the total of 30) General Medicine primary procedures correct 90.00% (18 out of the total of 20) Trauma and Orthopaedic primary procedures correct 70.73% (29 out of the total of 41) A breakdown of the errors by their associated error types are shown below (see Appendix 4 for detailed explanation of the error keys): Page 19 of 37

20 Error Key Number of Errors Percentage of Primary Procedures with Error PP % PP % PPO % PPNR % Primary Procedure Incorrect at 3 rd Character Level (PP3) There were 9 primary procedures (9.89%) incorrect at 3 rd character level. T64.4 Insertion of tendon into bone NEC Excludes: For stabilisation of joint (W77) O27.1 Extra-articular ligament reconstruction for stabilisation of joint The patient had a Patellofemoral ligament reconstruction and Osteotomy of the Tibial tubercle, T64.4 could not be used to code this operation as it was performed to stabilise the knee joint, and this is excluded from use as per the excludes note. This procedure was documented on the operation sheet that the coding staff would have access to at the time of coding Primary Procedure Incorrect at 4 th Character Level (PP4) There were 4 primary procedures (4.39%) incorrect at 4 th character level. U21.2 Computed tomography NEC U21.1 Magnetic resonance imaging NEC The patient had a MRI (Magnetic Resonance Imaging) scan in radiology and not a CT (Computed Tomography) scan. This was reported on the Welsh Clinical Portal that the coding staff would have had access to at the time of coding Primary Procedure Omitted (PPO) There were 7 primary procedure codes (7.69%) omitted. U13.6 Computed tomography of bone Includes: Computed tomography of joint During the admission the patient had a Computed Tomography scan of the knee joint which was not coded. This was reported on the Welsh Clinical Portal which coding staff had access to at the time of coding. Page 20 of 37

21 7.6.4 Primary Procedure Not Relevant (PPNR) There were 3 primary procedure codes assigned which were not relevant (3.29%). X29.2 Continuous intravenous infusion of therapeutic substance National Clinical Coding Standards OPCS 4 CSX2: Intravenous antibiotics, infusions and injections (X29.2) states Intravenous (IV) antibiotics/infusions/injections must only be coded if the patient is admitted solely for the administration of IV antibiotics/infusions/injections. In this admission the patient was admitted for general treatment of a wound infection, part of which was treatment with IV antibiotics. 7.7 Secondary Procedure Codes There were 204 secondary procedures codes assigned. These secondary procedure codes were 74.51% correct (152 out of the 204 secondary procedures). They were broken down by specialty as follows: General Surgery secondary procedure correct 87.50% (56 out of the total of 64) General Medicine secondary procedure correct 82.75% (24 out of the total of 29) Trauma and Orthopaedic secondary procedure correct 55.85% (62 out of the total of 111) A breakdown of the errors by their associated error types are shown below (see Appendix 4 for detailed explanation of error keys): Error Key Number of Errors Percentage of Secondary Procedures with Error SP % SP % SPIS % SPO % SPNR % Secondary Procedure Incorrect at 3 rd Character Level (SP3) There were 2 secondary procedure codes (0.98%) incorrect at 3 rd character level. L76.9 Endovascular placement of stent unspecified O20.9 Endovascular placement of stent graft unspecified The theatre operation sheet which would have been available to the coding staff at the time of coding, states that a stent graft was placed rather than a stent. Page 21 of 37

22 7.7.2 Secondary Procedure Incorrect at 4 th Character Level (SP4) There were 4 secondary procedure codes (1.96%) incorrect at 4 th character level. U21.2 Computer tomography NEC U21.2 Computer tomography NEC Y98.2 Radiology of two body areas Y98.5 Radiology of >4 body areas During this admission 5 body areas (head, cervical vertebra, chest, abdomen and pelvis) were scanned during one trip to radiology. Scans and times were available on the Welsh Clinical Portal that the coding staff would have had access to at the time of coding Secondary Procedure Incorrectly Sequenced (SPIS) There was 1 secondary procedure code (0.49%) which was incorrectly sequenced. W74.2 Reconstruction of intra-articular ligament NEC W74.2 Reconstruction of intra-articular ligament NEC Y76.7 Arthroscopy approach to joint Y76.7 Arthroscopy approach to joint Y71.3 Revisional operations NOC Y71.3 Revisional operations NOC Y65.8 Harvest of tendon other specified Z84.6 Knee Joint Z60.9 Muscle NEC Y65.8 Harvest of tendon other specified The site code for the knee joint was incorrectly sequenced National Clinical Coding Standards OPCS 4 GCS12: Coding grafts and harvests of sites other than skin gives the following sequence: Body system chapter code classifying the organ/site being grafted Chapter Z site code identifying the specified site/organ being grafted (if this is not already identified within the body system code) Secondary Procedure Omitted (SPO) There were 45 secondary procedure codes (22.05%) omitted. U13.6 Computed tomography of bone Includes: Computed tomography of joint Y98.1 Radiology of one body area Z84.6 Knee Joint During the admission the patient received a Computed Tomography scan to their knee joint. This radiological procedure was documented on the Welsh Clinical Portal which the coding staff had access to at the time of coding. The coding staff omitted to assign codes for this procedure, as per guidance in Clinical Coding Standards OPCS 4 CSU1: Diagnostic imaging Procedures (U01-U21 and U34-U37) Page 22 of 37

23 7.7.5 Secondary Procedure Not Relevant (SPNR) There were 15 secondary procedure codes assigned which were not relevant (7.35%). U35.4 Computed tomography of pulmonary U35.4 Computed tomography of pulmonary arteries arteries Y98.1 Radiology of one body area Y98.1 Radiology of one body area Z40.1 Pulmonary artery The assignment of Z40.1 site code is not relevant as the site of procedure in inclusive within the Diagnostic Imaging code U35.4. As per guidance in Clinical Coding Standards OPCS 4 Rule 7: Subsidiary Chapters Y and Z. 7.8 Case Note Findings The case notes used in the audit were in generally in a poor state and very difficult to extract the relevant information from. The auditors encountered the following issues: A large number of the operation sheets were incomplete, and those that were complete often contained conflicting information concerning the procedure performed. The case notes were bulky and in poor physical condition. The case notes have named sections with dividers. However, patient information was randomly filed throughout the case note. For example, admission sheets filed within the section for letters and other communications. This substantially increased the time which was required to code/audit the case notes, as to ensure that all relevant information was extracted for an episode, all sections had to be checked. Clinical conclusions and the admission and discharge letters which should be present at the end of each consultant episode were in a large number incomplete, missing, and illegible or had differing primary/secondary diagnoses. Compounding the coding staffs difficulties in identifying and extracting the relevant information necessary to accurate code the admission Diagnoses that differ with each responsible clinician. For example clinicians swapping between diagnosing Acute Coronary Syndrome and unstable angina within the same spell or episode. Illegible hand writing and poor carbon copies (especially the admission and discharge letters) Missing days of information, where there was no daily written entry by the responsible clinician. Page 23 of 37

24 Documents not dated or signed by clinical staff and the wrong date being entered, lead to difficulty when trying to identify start of admission especially for those patients admitted through Accident and Emergency. This resulted in admissions not being filed in chronological order. The above issues were represented across the entire sample of case notes examined, and appeared to be representative of the general condition of the case notes. 8 Conclusions 8.1 The coding accuracy for the Primary diagnosis has improved from 70.97% in the previous audit to 88.70%; this is in large part due to the system of coding the case notes on the wards onto proformas having been abolished. At the time of auditing all episodes (with the exception of endoscopies) were now being coded from the case notes (within the clinical coding department) straight on to the PAS (Myrddin) via the encoder (Medicode), with additional information being available to the coding staff on electronic systems (Welsh Clinical Portal, Theatres, Maternity and Intensive Care systems) 8.2 The coding accuracy of Secondary Diagnoses fell from 64.60% in the previous audit to 63%. The Auditors calculated that 30% of these secondary diagnosis errors were due to co-morbidities being omitted by the clinical coding staff despite being recorded in the case notes. 8.3 The coding staff in the Royal Glamorgan Hospital are all up to date with their mandatory training and generally demonstrate a sound grasp of national clinical coding rules and standards. 8.4 The lack of staff with the ACC qualification is a concern, since it prevents the organisation from being assured that its coding staff are coding to a recognised national standard and it makes it impossible to ascribe a baseline level of expertise to the clinical coders in the Royal Glamorgan Hospital. 8.5 Endoscopy/sigmoidoscopy/colonoscopy and bronchoscopy sheets provide detailed information for coding the procedure undertaken. However, they do not state a definitive diagnosis which may differ from the reason for admission and may not contain any of the patient s co-morbidities 8.6 The auditor experienced difficulties due to the poor condition of the case notes, which exacerbates the problems experienced by the coding staff when trying to code to rigid timeliness and accuracy targets. 8.7 A lack of regular clinical coding audits and assessments has lead to a situation where individual coding staff (especially band 3 trainees) are not receiving well timed and comprehensive feedback on their coding quality. 8.8 The auditors noted that there has been an effort to enhance the clinical involvement with the coding department; through initiatives such as the clinical coding bookmark application and regular attendance of the clinical coding team at the SHO s induction days. However, the clinical coding department has sill to establish a clinician validation programme. Page 24 of 37

25 9 Recommendations 9.1 The clinical coding staff must be made aware of the importance of identifying and assign the codes for all the co-morbidities and management must ensure that they are given adequate time and resources to allow them to extract all the relevant data. Especially when coding complex and long stay admissions. 9.2 Clinical coding staff should continue to attend all mandatory training sessions and speciality workshops in order to maintain their competency. 9.3 Continual review of individual s workloads and activity should be conducted at regular intervals by the coding management team. To ensure that any targets allocated to coders take into account any extra duties (i.e. mentoring or attendance at meetings) that the coder might be undertaking as part of their personal development, and the complexity of the admissions that they are coding. 9.4 The Clinical coding auditor/supervisor along with the clinical coding manager should immediately put into action a programme to regularly audit the accuracy of individual coders. Particularly attention should be given to the auditing of the episodes coded by the band 3 trainees. The results of these audits should be fed back to the coding staff as part of their regular professional development reviews, beginning with the next round of reviews. 9.5 Lead consultants for each speciality should be engaged to initiate a coding validation programme. This will increase the quality of the coded data in terms of standards and optimise the coding for the benefit of the organisation and clinical departments. 9.6 The auditors noted that working groups have been initiated to improve the condition and quality of the case notes this is a work in progress group, and results will be verified during the current financial year. The senior coding team should commence a programme to substantiate the outcome of each incident reported to ensure that they are acted upon. 9.7 The clinical coding manager should engage with the clinician responsible for the endoscopy report, to ensure that a definitive diagnosis and a comprehensive list of comorbidities are recorded on the report, if the coding from the full case notes is not feasible. 9.8 A further, large scale audit of the clinical coded data in the Royal Glamorgan Hospital should be carried out to validate the findings of this audit and to additional clarify any areas that need improvement for the future development of the department and individuals. Page 25 of 37