Payment by Results: Clinical Coding Issues

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Payment by ResultsClinical Coding Issues
Janet Kempson Data Quality Clinical Coding
Manager Cheshire Merseyside
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Outline

• Terming, Classifying, Grouping
• The Coding Process
• HRGs
• Coding examples
• Coding issues

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THE PATIENT
NCRS NSFs
Decision support SNOMED CT
Care pathways CLINICAL TERMS
TERMING Clinical Clinical
audit READ
Research
Summarising
CDS NationalInternational
ICD-10 OPCS-4/NCoI CLASSIFYINGStatistics
Costing
GROUPS GROUPINGCommissioningPayment by
Results Needs assessment
HRGsClinical Audit Other
groupsHealth care research
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Statistical Classifications

• a system of categories to which morbid entities
  are assigned according to established criteria
  ICD10 Vol 2 Ch 2
• Every disease or morbid condition must have a
  definite and appropriate place as an inclusion in
  one of the categories of the statistical
  classification ICD 9 Vol 1 page vii.
• Statistical classifications have rules (i.e. The
  Coding Frame) to ensure uniformity, which is
  essential if the information is to be of use.

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THE PATIENT
NCRS NSFs
Decision support SNOMED CT
Care pathways CLINICAL TERMS
TERMING Clinical Clinical
audit READ
Research
Summarising
CDS NationalInternational
ICD-10 OPCS-4/NCoI CLASSIFYINGStatistics
Costing
GROUPS GROUPINGCommissioningPayment by
Results Needs assessment
HRGsClinical Audit Other
groupsHealth care research
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The Coding Process

• The coding process is the translation of medical
  terminology into codes of the statistical
  classifications.
• Medical terminology describing the reason for a
  patients encounter appears on a source document
  e.g. case notes, discharge letters, clinical
  work-sheets, discharge proformas.

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The Coders Role

• The coders role is to extract the relevant
  information from the case note and to assign
  codes which represent a complete picture of the
  patients current care.
• All codes assigned must represent an accurate
  translation of the diagnostic statements or
  terminology used by the clinician

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General Rules for Coding

• Code every problem which affects the care, or
  influences the health status or is the reason for
  the hospital stay on the episode being coded.
• Code the minimum number of codes which accurately
  reflect the patients care on the encounter.
• Code each problem to the furthest level of
  specificity available in the classification.

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Definition of Primary Diagnosis (HES WHO)

• The first field(s) of the coded clinical record
  will contain the main condition treated or
  investigated during the relevant episodes of
  healthcare.
• Where there is no definitive diagnosis, the
  main symptom, abnormal findings, or problem
  should be selected as the main condition.

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Healthcare Resource Groups

• Each group contains a set of treatments that
  are clinically similar and that use roughly
  the same level of resources.

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HRG Chapters
A Nervous SystemB Eyes PeriorbitaC
Mouth, Head, Neck EarsD Respiratory SystemE
Cardiac Surgery Primary Cardiac ConditionsF
Digestive SystemG Hepato biliary
Pancreatic SystemH Musculoskeletal SystemJ
Skin, Breast BurnsK Endocrine Metabolic
System
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HRG Chapters (continued)
L Urinary Tract Male Reproductive SystemM
Female Reproductive SystemN Obstetrics
Neonatal CareP Diseases of ChildhoodQ
Vascular SystemR Spinal Surgery Primary
Spinal ConditionsS Haematology, Infectious
Diseases, Poisoning and Non- Specific
GroupingsT Mental HealthU Undefined Groups
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Admitted Patient Care Data Items

• Primary and secondary procedures
• Primary and secondary diagnoses
• Age
• Sex
• Method of Discharge
• Legal Status
• Length of Stay

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Version 3 Algorithm - Part One
ValidPDx
U01 Primary Diagnosis(PDx) Invalid
No
Yes
ProcedureRecorded
Group UsingDiagnosis (Dx)
No
Yes
AnyProcedureValid
U02 PrimaryProcedure Invalid
No
Yes
Select Highest Hierarchical Procedure
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Version 3 Algorithm - Part One (continued)
AnySignificantProcedure
Group UsingDiagnosis (Dx)
No
MinorProcedure LOSgt 1 Day
Group UsingDiagnosis (Dx)
Yes
No
Group UsingSelected Procedure
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Version 3 Algorithm - Part Two
Group UsingDiagnosis (Dx)
Select Primary Diagnosisor Secondary Diagnosis
if Dagger and Asterix Code
Any Dxof Holiday ReliefCare
S24 Holiday Relief Care
Yes
Any Dxor Px of Chemo-therapy
Chemotherapy Group(C98, D98 etc.)
Yes
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Version 3 Algorithm - Part Two (continued)
TwoMajor Dxs andAgegt 69
Complex Elderly Group(A99, C99 etc.)
Yes
Any Dxof Planned Procedurenot carried out
S22 Planned Procedurenot carried out
Yes
Group UsingSelected Diagnosis
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Undefined Groups

• U01 Invalid Primary Diagnosis
• U02 Invalid Dominant Procedure
• U04 Age Outside Range 0-130
• U05 Age Conflicting with Diagnosis or Procedure
• U07 Poorly Coded Primary Diagnosis
• U08 Poorly Coded Dominant Procedure
• U09 Invalid Length of Stay

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Chapter J Skin, Breast Burns Surgical Groups
V3
ProcedureGroups
Complex BreastRecon Using Flaps
J01
Maj Breast SurgeryInclude Plastic PX
Agegt49 orwith cc?
Yes
J02
No
J03
Agegt49 orwith cc?
Yes
Intermediate BreastSurgery
J04
No
J05
Agegt69 orwith cc?
Yes
Minor BreastSurgery
J06
No
J07
Lymph DissectionProcedures
J11
Soft TissueProcedures
J12
1
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Example of incomplete coding 1

• Incomplete coding
• D05.1 (ICD10) Intraductal carcinoma in situ
• B28.3 (OPCS) Excision of lesion of breast
  (lumpectomy)
• HRG J05 Costs 853
• Correct Coding
• D05.1 (ICD10) Intraductal carcinoma in situ
• I10 (ICD10) Hypertension
• B28.3 (OPCS) Excision of lesion of breast
  (lumpectomy)
• HRG J04 Costs 1094

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Example of incomplete coding 2
Incomplete coding I21.1 (ICD10) Acute
transmural myocardial infarction of inferior
wall I44.1 (ICD10) Atrioventricular block,
second degree HRG E12 Costs 2037 Correct
Coding I21.1 (ICD10) Acute transmural
myocardial infarction of inferior wall I44.1
(ICD10) Atrioventricular block, second
degree K60.1 (OPCS) Implantation of intravenous
cardiac pacemaker Y70.5 (OPCS) Temporary
operations HRG E07 Costs 4659
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Example of incomplete coding 3
Incomplete coding C18.7 (ICD10) Cancer sigmoid
colon H10.9 (OPCS) Excision of sigmoid colon
NOS HRG F32 Costs 4812 Complete coding C18.7
(ICD10) Cancer sigmoid colon H10.5 (OPCS)
Excision of sigmoid colon colostomy H15.2
(OPCS) End colostomy HRG F31 Costs 5604
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Example of incomplete coding 4
Incomplete coding C75.1 (OPCS) Insertion of
prosthetic replacement of lens C74.9 (OPCS)
Unspecified extraction of lens HRG B14 Costs
847 Complete coding C75.1 (OPCS) Insertion of
prosthetic replacement for lens C71.2 (OPCS)
Phakoemulsification of lens HRG B13 Costs 715
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Example of incomplete coding 5
Incomplete coding (aged 68 years) S46.9 (ICD10)
Injury of unspec muscle tendon at shoulder
upper arm level X50.0 (ICD10) Overexertion
strenuous or repetitive movements T67.9 (OPCS)
Primary repair of tendon unspecified Z54.5
(OPCS) Muscle of upper arm (triceps
brachii) Z94.2 (OPCS) Right sided
operation HRG H19 Costs 1435 Complete
coding (aged 68 years) S46.9 (ICD10) Injury
of unspec muscle tendon at shoulder upper arm
level X50.0 (ICD10) Overexertion strenuous or
repetitive movements Z60.2 (ICD10) Living
alone T67.9 (OPCS) Primary repair of tendon
unspecified Z54.5 (OPCS) Muscle of upper arm
(triceps brachii) Z94.2 (OPCS) Right sided
operation HRG H18 Costs 4262
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The Financial Impact

• Trust income could be at risk if
• 100 of episodes are not coded within the
  required timescales
• there are any HRG U codes
• there are missing CCs
• there are any coding errors

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IG Toolkit - Requirement 7302

• Has the Trust had an external audit of clinical
  coding based on national standards within the
  last 12 months?
• The Trust has evidence that there are established
  procedures for the regular assessment of clinical
  coding. The results of an external clinical
  coding audit based on the requirements and
  standards within the Data Quality Audit
  Framework for Coded Clinical Data and undertaken
  by external staff registered on the approved list
  of clinical coding auditors within the last
  twelve months are noted and actioned.

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IGT Clinical Coding Audit

• Level 1
• - established procedures for regular internal
  audit
• - at least one audit by external staff in the
  last 12 months. 
• Level 2
• - established procedures for regular internal
  audit
• - an external audit in last 12 mths based on
  requirements and standards of the national
  framework, undertaken by staff registered on the
  national approved list of clinical coding
  auditors.
• Level 3
• - as Level 2 plus accuracy scores should be gt
  or to Diagnosis Primary - 90 Secondary -
  80
• Procedure Primary - 90 Secondary - 80

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Coding Issues Incompleteness/Inaccuracies

• Use of discharge summaries as the main source
  document missing CCs
• State of casenotes
• Patient transfers
• Training coders must keep up-to-date
• Insufficient internal audit
• Insufficient involvement of clinicians

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Coding Issues - Timeliness

• End of quarter/end of year catch up is not good
  enough for PBR
• Must now meet Flex and Freeze dates
• Issues affecting timeliness include
• - Source documentation
• - Coding resources
• - Training period (12 - 18 months)
• - Recruitment and retention of staff

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Source Documentation

• Case notes to coders need clerical support
• Coders to case notes - problems working on wards
• Proformas vs. case notes
• Speed vs. depth of coding
• Review final discharge letter for full accurate
  coding
• But this means coding twice which impacts on
  resources

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Coding Resources

• 7,500 FCEs per WTE coder p.a. (additional
  requirement for OPD
• Supervisor must be additional (role includes
  checking work of trainees, regular internal
  audits, training development of all coders)
• 12-18 month training period for new coders
• Update training for experienced coders
• Departmental structure

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Coders Training Programme

• Year 1
• Foundation Course with 6 and 12 month reviews
• Year 2
• Anatomy Physiology workshop
• Specialty workshops
• Year 3
• Refresher course
• Preparation for Qualification

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Recruitment and Retention of Coders

• Appropriate grading structure
• Agenda for Change
• Appropriate selection criteria for new entrants
• Opportunities for trained coders in primary care,
  information management, clinical audit, etc.
• Acute trusts are the training ground
• Coders are worried about the future.

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The Future

• NCoI impact of training implementation
  period, need to recruit extra resources now
• NHS Care Records Service
• SNOMED CT
• Templates, pick lists, cross mappings, etc.
• The role of the coder will change over the next
  10 years.
• Coders will need to be supported with ETD and
  good leadership during the changes
• or PBR could be at risk

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Final Thought
Correct and complete Clinical Coding relies on
both the skills of well trained coders and the
provision of accurate information recorded in
clinical records.. BUT - this is a trust wide
responsibility, not just the coders.