Policy Title: Policy and Procedure for Clinical Coding Reference and Version No: IG7 Version 6 Author and Job Title: Caroline Griffin Clinical Coding Manager Executive Lead - Chief Information and Technology Officer Validated By Information Management and Governance Group Ratified By: Digital Strategy Board Policy Summary This policy describes the procedures to follow when carrying out clinical coding within the Trust. The policy aims to standardise the coding process which should result in good practice and the production of consistent information. The policy also outlines the importance of coding within the Trust, the validation of coded data, individual responsibilities and staff management within the department. There is also an area, at the end of the policy, to record changes in code assignment for example local policies and training courses attended. Date Issued: 24 May 2017 Date for Review: 20 April 2020 Related Documents IG5 Data Protection Policy This Policy is Intended for: Information Management Department The Trust is committed to the fair treatment of all, regardless of age, colour, disability, ethnicity, gender, gender reassignment, nationality, race, religion or belief, responsibility for dependants, sexual orientation, trade union membership or non membership, working patterns or any other personal characteristic. This policy and procedure will be implemented consistently regardless of any such factors and all will be treated with dignity and respect. To this end, an equality impact assessment has been completed on this policy. 1 of 22 (Date for review 20 April 2020)
Policy Revisions Change Control The table below identifies the areas where this policy has been reviewed; where these are minor changes staff should ensure that they take this opportunity to refresh knowledge of the whole policy and their responsibilities in relation to this and not just focus on the minor changes. Policy Ref Version Number Revision to Page IG7 V5 P6, 2.3 Description of Revisions Made HRG v4.5 changed to HRG4 16/17 Approved Date P6, 2.4 3M Medicode version 5.20.12 changed to Woodward Associates Simplecode. The system is integrated into the TrakCare System. It is smartcard controlled to ensure confidentiality. P6, 2.5 100% within 13 working days changed to 100% within 8 working days P7, 3.2, iii EasyAudit software version 6.0 10.0 P7, 3.2, iv Clinical Coding Audit Methodology Version 6.0 10.0 P8, 3.5, i & 4.1, ii & 5.1, i Basic Clinical Coding Foundation Course changed to Clinical Coding Standards Course P13, 6.3 Delete, i, iv), v), vi) P19, 6.9, i The coders at North Tees are based in the main coding office and Osmotherley House Throughout policy Throughout policy Throughout policy Throughout policy Throughout policy PAS changed to TrakCare Medicode changed to Simplecode ICD-10 4 th Edition changed to 5 th Edition OPCS-4.6 changed to OPCS-4.7 HSCIC changed to NHS Digital 2 of 22 (Date for review 20 April 2020)
Contents 1. Introduction 1.1 Responsibilities 1.2 Policy statement 1.3 Statement of purpose 2. Clinical coding information 3. Validation of clinical coded information 4. Clinical coding training 5. Communication in clinical coding 6. Procedures for Clinical Coding 7. Entering Clinical Codes onto TrakCare via Simplecode 8. Monitoring Appendices Appendix 1 Form A: Appendix 2 Form B: Details of local policies Clinical Coding Training Programme 3 of 22 (Date for review 20 April 2020)
1. Introduction This policy and procedure document has been produced with the intention of promoting good practice and producing consistency of information during the clinical coding process within the Trust. The purpose of the document is to ensure that there is a framework for staff to follow which standardises the Clinical Coding Process. The role of the Clinical Coding Department is to produce accurate, complete and timely coded clinical information. All coders should be following the national classifications for diagnosis ICD-10 and procedures OPCS-4. The Trust supports coders to work towards gaining the National Clinical Coding Qualification (UK) to become Accredited Clinical Coders. All new staff within the department are required to attend a Clinical Coding Standards Course and experienced coders are required to attend a coding refresher course every 3 years. 1.1 Responsibilities Head of Information Management - has overall strategic responsibility for the Clinical Coding Department. Clinical Coding Manager - has operational day to day responsibility across both sites and is responsible for the production of high quality clinical information in both a timely and accurate manner. It is their responsibility to ensure all staff involved in Clinical Coding receive regular training to maintain and develop their coding skills and that they are all aware of the importance of security and confidentiality when dealing with patient identifiable information. The coding manager will also ensure that this policy document is updated and maintained every six months to ensure the policies and procedures documented are kept in line with current activities. The person specified will also ensure that the department achieves the policies and procedures outlined in this manual. Clinical Coding Audit Manager - is responsible for carrying out regular audits on coded data and on source documentation. It is their responsibility to follow up issues highlighted by audits and to ensure staff receive relevant training. The Audit Manager will oversee coding of deceased patients in order for department to contribute to accurate HSMR and SHMI rates by coding episodes as accurately as possible and ensuring they provide a comprehensive picture of the patient s stay. Clinical Coding Trainer - is responsible for all the coding training within the Trust, including the delivery of all NHS Digital approved training courses. In addition, they also have the same responsibility as the Clinical Coding Officers. Specialist Clinical Coding Officers - are responsible for liaising with clinicians within their directorate to promote coding and improve quality of information. They also have the same responsibility as the Clinical Coding Officers. Clinical Coding Officers - are responsible for recording all clinical coded information on the TrakCare system within the designated timescales. 4 of 22 (Date for review 20 April 2020)
Clinical Coding Assistants - are responsible for carrying out the administrative duties within the department with particular emphasis placed on providing the coding source documentation for the coding officers. 1.2 Policy Statement i) All procedures involved in the capture of information for clinical coding purposes are clearly defined in this Policies and Procedure Manual for all specialties to ensure compliance and clarification of individual coding processes. All quality assurance procedures for the clinical coding department are detailed in this Policies and Procedures Manual including audit and data quality measures, to ensure continual improvements in the standard and quality of coded data in the Trust. i All changes to clinical coding policies and/or procedures are detailed in this Policies and Procedures Manual in the appropriate manner to ensure all contributors are in agreement with the current practice. Any alterations to clinical coding practice have change and implementation dates provided within this document, and comply with national standards and classification coding rules and conventions. iv) All clinical coding policy and procedure decisions made between the Clinical Coding Department and individual clinicians are fully described, agreed and signed by the relevant personnel within this document. All policies or procedures agreed within the documentation do not contravene national standards or classification coding rules and conventions. v) All training plans for members of the Clinical Coding Department and those involved in the clinical coding process are clearly defined and documented in this document. vi) Details of communication arrangements are detailed to ensure effective dissemination of information regarding coding, resolutions to queries and changes in coding practice to all coding staff and users of the information. v All confidentiality and security issues incurred during the coding process are detailed in this document to ensure adherence to local and national policies, and have been agreed by the person responsible for the coding staff. 1.3 Statement of Purpose i) To provide accurate, complete, timely coded clinical information for use both within the Trust and for external returns on behalf of the Trust represented by the Clinical Coding Department. To adhere to national standards and classification rules and conventions as set out in the WHO ICD-10 5 th edition volumes 1-3, ICD-10 5 th Edition Reference Book, OPCS-4.7 volumes 1 and 2, OPCS-4.7 Reference Book and the Coding Clinic on the NHS Digital website. 5 of 22 (Date for review 20 April 2020)
i To input onto the TrakCare system, accurate and complete coded information within the designated time scales to support the information requirements and commissioning of the Trust. iv) To provide accurate, consistent and timely information to support Clinical Governance and the Data Accreditation Process. v) To ensure all staff involved in the clinical coding process receive regular training to maintain and develop their clinical coding skills, regardless of experience and length of service. vi) To ensure continual improvement of clinical coded information within the Trust through systematic audit and quality assurance procedures. v To ensure all staff are aware of the Trust s security and confidentiality policies when using patient identifiable information. 2. Clinical Coding Information 2.1 Use and Importance of Clinical Coding Data Clinical coded data forms part of the in-patient care given by the Trust and is used both internally and externally by the Trust e.g. internally used by the Assistant Directors to help them manage their services efficiently, and externally used by many different organisations both regionally and nationally to help plan and deliver appropriate health care using the information from Trusts. The role of clinical coding within Trusts is becoming more and more important. The introduction of the new Financial Flows Payment by Results means payments to the Trust are linked to the actual activity undertaken. Therefore each coded Finished Consultant Episode (FCE) must accurately reflect the hospital stay of the patient and the amount of resources used. 2.2 Source Documentation Case notes are used as the source of information in the following specialties across both sites; Obstetrics / Gynaecology Endoscopy Day Case Surgery A&E General Surgery Oral Surgery Orthopaedics Urology The information relating to the relevant FCE is extracted from the clinical records within the case notes. This includes discharge summaries, clinical notes, test results, operation sheets, GP letters etc. Electronic discharge summaries are used as the source documentation for Paediatrics and General Medicine. 6 of 22 (Date for review 20 April 2020)
The Electronic Patient Record is currently being used within the Trust and the coding department currently receives electronic discharge summaries from the following directorates; General Medicine General Surgery (male and female) Gynaecology Orthopaedics Paediatrics Urology The discharge summaries are accessed by the coding department via TrakCare on a daily basis. In order for an accurate code to be assigned the discharge summaries must contain information regarding primary and secondary diagnoses and primary and secondary procedures. If inadequate information is provided on the summary, the case notes are located and the relevant information is extracted from the clinical records (clinical notes, operation notes, GP letters etc.). If the case notes cannot be located, as a last resort, admission information is extracted from the electronic bed occupancy list, that is available on the intranet, and coded on the relevant FCE. If, at a later date, more accurate information is received by the coding department, the relevant coded record is updated with the new information. All coders have access to the ICE system on both sites and, if relevant, access the pathology results at the time of coding. If the results are not available at the time of coding the patients details are recorded and the results are viewed at a later date and the coding updated if necessary. 2.3 Coding details The classifications currently used to code inpatient data are ICD-10 5 th Edition and OPCS-4.7. Every member of the coding team has their own personal copy of each classification and it is their responsibility to keep them up to date. The Healthcare Resource Grouper used is HRG 4 16/17 on-line Grouper. 2.4 Coding Aides The coding software used to enter the diagnosis and procedure codes onto the hospital information system is Woodward Associates Simplecode. The system is integrated into the TrakCare system. It is smartcard controlled to ensure confidentiality. 2.5 Timescales Due to the introduction of the Financial Flows mentioned above and Healthcare Resource Groups the deadlines for all discharged patient episodes to be coded are as follows. The department needs to be 90% coded within 3 working days of the month end and 100% within 8 working days of the month end. The coders regularly produce lists of un-coded episodes using the Qlikview system. This list is used by the coders to identify which patients the department has not received discharge information for. 7 of 22 (Date for review 20 April 2020)
3. Validation of Clinical Coded Data (Policy Monitoring) 3.1 Audit i) The Trust recognises the importance of producing accurate coded clinical information and therefore regular internal audits of clinical coding are carried out on the following areas; coded clinical data clinical coding processes all documentation provided for that purpose. The areas identified as requiring auditing are documented in the audit forward plan. Ongoing internal audits on individual coders are carried out. The audit involves initially reviewing the coding of a random sample of 50 sets of case notes for each individual coder. The results of the audit are fed back individually to the coder concerned along with any recommendations and training requirements that have been identified. The coder is given time, and support, to improve their coding practice before a re-audit is carried out. i An annual Information Governance (IG) Toolkit audit is carried out, by the Clinical Coding Audit Manager, on a sample of 200 finished consultant episodes. In order for the Trust to attain level 2 within the IG toolkit an accuracy rate of 90%, for primary diagnosis and primary procedure, and 80%, for secondary diagnosis and secondary procedure, has to be attained. iv) An external Payment by Results audit is carried out on a regular basis, by the Audit Commission, on a sample of 200 finished consultant episodes. 3.2 Audit Methodology i) Internal audits are carried out by the Clinical Coding Audit Manager. It is their responsibility to carry out the entire audit from design through to report writing and dissemination of results. Strict confidentiality is maintained at all times both with regard to patient identifiable information and clinical coder identification. Patients to be included within the audit are identified via the Information Department from the TrakCare download. i During the audit information is extracted from the case notes. The auditor s codes, and any resulting error codes, are recorded on Woodward Associates EasyAudit software version 10.0. The software is used to compare the coded information recorded by the coders and the auditor s codes and analyse any coding errors found. iv) The audits are carried out using the methodology detailed in the NHS Classification Service publication Clinical Coding Audit Methodology Version 10.0. 8 of 22 (Date for review 20 April 2020)
v) The results of any audits carried out are disseminated to each member of the coding department and the reports distributed to relevant members of the Information Department. vi) The Clinical Coding Audit Manager has undertaken the NHS Information Authority s Basic / Advanced Audit Workshop. 3.3 Implementing Change i) The Clinical Coding Manager and the Clinical Coding Audit Manager, in conjunction with the Head of Information Management, are responsible for implementing change as a result of the audit outcome. Members of the Clinical Coding Department are informed of any changes to be implemented via e-mail or the regular team briefing session. The changes, introduced via the team brief, are documented in the minutes which are sent to all members of the team via e-mail. If any member of the team is not present at the team briefing session they are informed of the change as soon as possible after the briefing. i If there is an urgent change that needs to be implemented each member of the coding team is informed of the change by e-mail. 3.4 Local Policies i) All local coding policies are documented in the policies and procedures manual and have been agreed with medical staff. Each coder is informed of any local policy and is required to sign the relevant form to document that they have been made aware of the policy. (Form A) 3.5 National Standards Updates i) All members of the Coding Department, who have attended the Clinical Coding Standards Course, have their own personal copy of the ICD-10 5 th Edition Reference Book and the OPCS-4.7 Reference Book. All coders have access to the Coding Clinic that is available on the NHS Digital web site. When the Coding Clinic is updated an e-mail is sent to all coders from the Clinical Coding Trainer so they are aware when a new version is published. It is the coders responsibility to ensure they understand the information that is detailed in the Coding Clinic and that they update their books accordingly. 4. Clinical Coding Training 4.1 Training Programme for Clinical Coders i) All coders within the department are encouraged to attend internal and external training to ensure they keep up to date with the rules and conventions of ICD-10 and OPCS-4. Training also helps to create an awareness of the importance and eventual use of the coded data. All newly appointed novice coders are required to attend the Clinical Coding Basic Foundation Course within 6 months of appointment. 9 of 22 (Date for review 20 April 2020)
i Experienced coding staff are required to attend the Clinical Coding Refresher course every 3 years. iv) Coders are given the opportunity to attend regular specialist training courses whenever they are available. v) Wherever possible coding training is delivered in-house by the Clinical Coding Trainer. The training will be delivered by a NHS Classifications Service approved trainer and the courses will be delivered using NHS Digital training materials. The training will include standards courses, refresher courses and specialty workshops. vi) All coders are encouraged to keep their IT computer skills up to date. This includes attending TrakCare training sessions, e-mail and internet training and on-line Microsoft Office Skills Training. v Coding department staff are required to complete all Trust statutory training. This includes Information Governance, Health and Safety, Fire Training, Manual Handling COSHH, VDU Regulations and Protective Clothing and Equipment. vi Coding staff are responsible for recording the details and dates of any training courses they attend. 4.2 In House Career Structure for Coding Staff i) All coding staff are required to sit the National Clinical Coding Qualification (UK) within the timescales set out by NHS Digital. 4.3 Training of Non-Coding staff i) A presentation on clinical coding is delivered to the new intake of junior medical staff as part of their teaching. The presentation highlights the importance of coding within the Trust and the role medical staff play in providing the department with sufficient information for accurate codes to be assigned. Presentations are also delivered to specialty directorate meetings wherever possible. This can include multi-disciplinary meetings. 5. Communications in Clinical Coding 5.1 Internal and External Queries i) All coders who have attended the Clinical Coding Standards Course, have their own personal copy of the ICD-10 5 th Edition Reference Book and the OPCS-4.7 Reference Book and all coders have access to the Coding Clinic on the NHS Digital website. Those coders who have not attended the course have access to the above resources. The coding department endeavours to resolve internal queries within the department. If the query cannot be resolved within the department the appropriate clinical staff are contacted to determine if the query can be resolved within the Trust. 10 of 22 (Date for review 20 April 2020)
i If the query cannot be resolved internally it is referred to the National Clinical Classifications Helpdesk via the Clinical coding Query Mechanism available via the NHS Digital website iv) The outcome of the resolved query is circulated to all coding staff via the team meeting. 5.2 Internal Meetings i) A meeting / team briefing session is held with coding staff on a regular basis. Relevant departmental information, as well as Trust news, is disseminated to the coders. Specialist Coders are required to update the team on news from their own directorate. Coders are encouraged to participate in the meeting by contributing any information they think is relevant or to highlight any current issues within the department. The minutes are e-mailed to all members of the department and anyone who did not attend the meeting is given a copy of any handouts. Regular meetings are held between the Head of Information Management and the Clinical Coding Manager and Clinical Coding Audit Manager. The purpose of the meetings is to brief the Head of Information Management on the current status within coding and to discuss the strategic running of the department. i The Clinical Coding Manager holds regular one to one meetings with the Clinical Coding Trainer. The purpose of the meetings is to ensure the coding manager is kept up to date with any issues within the department and to discuss any training requirements. The Clinical Coding Manager also has regular one to one meetings with each member of the team to keep the Manager informed of their ongoing situation and any problems they may have. 11 of 22 (Date for review 20 April 2020)
6. Procedures for Clinical Coding 6.1 Summary of Source Documentation The source documentation used for coding purposes varies depending on the hospital site and specialty concerned. The following table lists the type of documentation used within each directorate and each site; Directorate Hartlepool North Tees A&E N/A Electronic Discharge Summary / Discharge Flimsy Gastroenterology Case notes / Endoscopy Report Case notes / Endoscopy Report Gynaecology Gynaecology infertility General Surgery Case notes / Electronic Discharge Summary Theatreman Report / Case notes Case notes / Electronic Discharge Summary Case notes / Electronic Discharge Summary N/A Case notes / Electronic Discharge Summary Haematology Discharge Flimsy Discharge Flimsy Medicine Electronic Discharge Summary Electronic Discharge Summary / Consultant Discharge Letter Obstetrics Case notes Case notes Orthopaedic Case notes / Electronic Discharge Summary / Theatreman Report Case notes / Electronic Discharge Summary Pain Theatreman Report Case notes / Discharge Flimsy Plastic Paediatrics Case notes / Electronic Discharge Summary Electronic Discharge Summary Case notes / Electronic Discharge Summary Electronic Discharge Summary Rheumatology Discharge Flimsy Electronic Discharge Summary Oral Surgery Case notes Case notes / Discharge Flimsy Urology Case notes Case notes / Electronic Discharge Summary 12 of 22 (Date for review 20 April 2020)
6.2 Procedures for Coding Flimsies i) Discharge flimsies are sent in the internal post to the coding office. Sort discharge flimsies into specialties. i Divide each specialty into monthly order. iv) Using the CRN number on the flimsy find the patient details on TrakCare. v) Select the appropriate episode. vi) Check the flimsy against the TrakCare record for accuracy e.g. Consultant/Speciality/Episode start and end dates. If there are any discrepancies verify with appropriate ward to ensure accurate information on TrakCare. v Translate clinical diagnosis and procedures from discharge flimsy into ICD-10 and OPCS-4 codes following the 4 step coding process. vi If insufficient information is provided on the flimsy in order for an accurate code to be assigned, the case notes will need to be reviewed and the additional information extracted. ix) Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine the histology results. If the histology result is unavailable at the time of coding the episode is coded using the information available and the episode is updated when the results become available. x) If any scans that require coding have been carried out check the PACS system to determine the type of scan carried out, the date of the scan, the number of body areas viewed and whether contrast was used. xi) On a regular basis carry out a system back up on all coded information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. At the North Tees site if the notes are not found, the on-call sheets from Emergency Admission Unit or ward registers may give the information required. i On receipt of case notes track in to department. iv) Extract required information from case notes. v) Translate and enter codes onto TrakCare. 13 of 22 (Date for review 20 April 2020)
6.3 Procedures for Coding Electronic Discharge Summaries i) Electronic discharge summaries are accessed on TrakCare on a daily basis. Translate clinical diagnosis and procedures from discharge summary into ICD-10 and OPCS-4 codes following the 4 step coding process. Also code any relevant co-morbidities. i If insufficient information is provided on the electronic summary in order for an accurate code to be assigned, the case notes will need to be reviewed and the additional information extracted. iv) Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine the histology results. If the histology result is unavailable at the time of coding the episode is coded using the information available and the episode is updated at a later date when the results become available. i) If any scans that require coding have been carried out check the PACS system to determine the type of scan carried out, the date of the scan, the number of body areas viewed and whether contrast was used. xi) On a regular basis carry out a system back up on all coded information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. At the North Tees site if the notes are not found, the on-call sheets from EAU or ward registers may give the information required. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) Translate and enter codes onto TrakCare. 6.4 Procedure for Clinical Coding- Obstetrics at Hartlepool and North Tees i) Collect case notes from Birthing Centre at University Hospital Of Hartlepool or the filing cabinet on the Obstetric ward at North Tees. If the notes are missing contact the secretary or go to the antenatal office to collect, the tracking system should show where the notes are located. Track case notes to coding. i Use the antenatal and postnatal booklets to code from. iv) Using the CRN number on the case notes find the patient details on TrakCare v) Select appropriate episode. 14 of 22 (Date for review 20 April 2020)
vi) Check case notes for accuracy against thetrakcare system e.g. Consultant/Specialty/Episode start and end dates. If there are any discrepancies verify with the appropriate ward to ensure accurate information on TrakCare. v Translate clinical diagnosis and procedures from case notes into ICD-10 and OPCS-4 codes for the mother following the 4 step coding process. Also code any relevant co-morbidities. vi Enter clinical codes onto TrakCare via Simplecode for mother. ix) Code episode for baby using ICD-10 and OPCS-4. x) Track case notes back to Maternity Assessment Unit at Hartlepool or obstetric ward at North Tees. xi) On a regular basis carry out a system back up on all coded clinical information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) If the case notes cannot be located or there is no information contained within the notes then the information should be extracted from documentation on the ward e.g. ward register, ward diaries etc. vi) Translate and enter codes onto TrakCare. 6.5 Procedures for Clinical Coding- Holdforth Unit, day case unit and Pregnancy Advisory Clinic at Hartlepool i) Case-notes are tracked and delivered to coding office by ward clerks or PAC staff. The case notes should be used as the coding source documentation but if they are unavailable the electronic discharge summary should be used. i Using the CRN number on the source documentation find the patient details on TrakCare. iv) Select the appropriate episode. v) Check the source documentation against the TrakCare record for accuracy e.g. Consultant/Speciality/Episode start and end dates. If there are any discrepancies verify with appropriate ward to ensure accurate information on TrakCare. 15 of 22 (Date for review 20 April 2020)
vi) Translate clinical diagnosis and procedures from source documentation into ICD-10 and OPCS-4 codes following the 4 step coding process. Also code any relevant co-morbidities. v Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine the histology results. If the histology result is unavailable at the time of coding the episode is coded using the information available and the episode is updated at a later date when the results become available. vi Track gynaecology, surgery and urology case notes and send to appropriate secretaries. Track and return orthopaedic, oral surgery, pain, plastic surgery and PAC case notes back to file. ix) On a regular basis carry out a system back up on all coded information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) If the case notes cannot be located or there is no information contained within the notes then the information should be extracted from documentation on the ward e.g. ward register, ward diaries etc. vi) Translate and enter codes onto TrakCare. 6.6 Procedures for Clinical Coding- Endoscopy Unit at Hartlepool i) The case notes are tracked and sent from the Endoscopy Unit to coding via the porter. The case notes should be used as the coding source documentation but if they are unavailable the Endoscopy GI Reporting tool should be used. i Use the CRN number on the case notes or summary to find the patient details on TrakCare. iv) Select the appropriate episode. v) Check the source documentation against the TrakCare record for accuracy e.g. Consultant/Speciality/Episode start and end dates. If there are any discrepancies verify with appropriate ward to ensure accurate information on TrakCare. vi) Translate clinical diagnosis and procedures from case notes into ICD-10 and OPCS-4 codes following the 4 step coding process. Also code any relevant co-morbidities. 16 of 22 (Date for review 20 April 2020)
v Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine the histology results. If the histology result is unavailable at the time of coding the episode is coded using the information available and the episode is updated at a later date when the results become available vi Track and send case notes to appropriate secretaries. x) On a regular basis carry out a system back up on all coded information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) If the case notes cannot be located or there is no information contained within the notes then the Endoscopy GI Reporting tool should be used vi) Translate and enter codes onto TrakCare. 6.7 Procedures for Clinical Coding- Orthopaedic at North Tees i) The Coding Assistant visits the ward on a daily basis and collects the case notes of the previous days discharges. The notes are taken to the coding office where they are coded. Track case notes to coding. i The case notes should be used as the coding source documentation but if they are unavailable the electronic discharge summary should be used. iv) Using the CRN number on the source documentation find the patient details on TrakCare. v) Select the appropriate episode. vi) Check the source documentation against the TrakCare record for accuracy e.g. Consultant/Speciality/Episode start and end dates. If there are any discrepancies verify with appropriate ward to ensure accurate information on TrakCare. v Translate clinical diagnosis and procedures from case notes into ICD-10 and OPCS-4 codes following the 4 step coding process. Also code any relevant co-morbidities. vi Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine the histology results. If the histology result is unavailable at the time of coding the episode is coded using the information available and the episode is updated at a later date when the results become available 17 of 22 (Date for review 20 April 2020)
ix) When coding is complete the case notes are sent to the relevant secretary or returned to file. xi) On a regular basis carry out a system back up on all coded information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) If the case notes cannot be located or there is no information contained within the notes then the information should be extracted from documentation on the ward e.g. ward register, ward diaries etc. vi) Translate and enter codes onto TrakCare. 6.8 Procedures for Clinical Coding- General Surgery & Urology In-Patient Episodes at North Tees i) The coder for general surgery and urology at North Tees is based in the coding office, ground floor, Middlefield Centre. The Coding Assistant visits the ward on a daily basis and collects the case notes of the previous days discharges. The relevant notes are collected from the Men s and Women s Health Unit s and SDU and taken to the coding office where they are coded. i Using the CRN number find the patient details on TrakCare. iv) Select the appropriate episode. v) Check the source documentation against the TrakCare record for accuracy e.g. Consultant/Speciality/Episode start and end dates. If there are any discrepancies verify with appropriate ward to ensure accurate information on TrakCare. vi) Translate clinical diagnosis and procedures from case notes into ICD-10 and OPCS-4 codes following the 4 step coding process. Also code any relevant co-morbidities. v Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine histology results. If the histology result is unavailable at time of coding the episode is coded using the information available and the episode is updated at a later date when the results become available. vi When coding is complete the case notes are returned to the relevant ward and placed in the appropriate filing cabinet. 18 of 22 (Date for review 20 April 2020)
x) On a regular basis carry out a system back up on all coded information. Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) If the case notes cannot be located or there is no information contained within the notes then the information should be extracted from documentation on the ward e.g. ward register, ward diaries etc. vi) Translate and enter codes onto TrakCare. 6.9 Procedures for Clinical Coding- Inpatients and day cases at North Tees i) The coders at North Tees are based in the main coding office and the Middlefield Centre. The coding assistants visit the wards on a daily basis and collect the case notes of the previous days discharges. The relevant notes are taken back to the coding offices where they are coded. i Using the CRN number find the patient details on TrakCare. iv) Select the appropriate episode. v) Check the source documentation against the TrakCare record for accuracy e.g. Consultant/Speciality/Episode start and end dates. If there are any discrepancies verify with appropriate ward to ensure accurate information on TrakCare. vi) Translate clinical diagnosis and procedures from case notes into ICD-10 and OPCS-4 codes following the 4 step coding process. Also code any relevant co-morbidities. v Enter clinical codes onto TrakCare via Simplecode software. If tissue has been sent to histology the ICE system should be reviewed to determine the histology results. If the histology result is unavailable at the time of coding the episode is coded using the information available and the episode is updated at a later date when the results become available. ix) On a regular basis carry out a system back up on all coded information. 19 of 22 (Date for review 20 April 2020)
Un-coded Episodes i) Reports are produced on a regular basis for any un-coded episodes. Trace case notes for un-coded episodes. i On receipt of case notes track to coding. iv) Extract required information from case notes. v) If the case notes cannot be located or there is no information contained within the notes then the information should be extracted from documentation on the ward e.g. ward register, ward diaries etc. vi) Translate and enter codes onto TrakCare. 7. Entering Clinical Codes onto TrakCare via Simplecode 7.1 TrakCare guidance for entering clinical codes Guidance on how to enter clinical codes into TrakCare can be found in the Simplecode reference document which is available on Sharepoint, the Trusts intranet site, by following the link below; http://trustnet/sitedirectory/information_management/user%20documenta tion/simplecodereferencedocument.pdf 8. Monitoring Clinical coding quality will be monitored on a monthly basis by the Clinical Coding Audit Manager. Any recurring coder issues will be reported back to the clinical coder involved by the coding audit team and training support will be offered where necessary. Coding issues caused by poor documentation will be discussed with appropriate clinicians. Coding data quality will be reported at each Information Management and Governance Group meeting, including results of audits carried out as part of the IG toolkit and local audits carried out to improve quality of clinically coded data. Reports from the various benchmarking systems will also be monitored to show any issues or improvements and the position of the Trust with regard to its peers. This will be reported at the Information Management and Governance Group meeting. 20 of 22 (Date for review 20 April 2020)
Form A: Details of Local Policies Appendix 1 This section includes details of any consultant specification coding and local clinical coding policies, which are not routinely recorded in the case notes i.e. local use of flexible bronchoscopies rather than rigid bronchoscopies. Local policy: Signed:. Job title:.. Date:. Seen by; Name of coder Signature of coder Date 21 of 22 (Date for review 20 April 2020)
Form B: Appendix 2 Clinical Coding Training Programme This form contains information regarding training courses clinical coding staff have attended and the dates of attendance. Name of coder:.. Training Course Attended Date of Attendance Signature of Manager 22 of 22 (Date for review 20 April 2020)