Plastic surgery audit codes: are the results reproducible?

Integrated clinical coding in urology – a novel way of working

Objectives:

The objective of this article is to report a completed cycle of audit of coding co-morbidities for bladder outlet surgery. We also present a novel way of working to achieve better accuracy in capturing admitted patient care data and coding in urology.

Materials and methods:

We undertook a retrospective case note and coding review of all bladder outlet surgeries performed in a single month. After initiating several measures to improve data recording and capture, we re-audited our results prospectively and analysed the results.

Results:

The initial accuracy of coding co-morbidities was 73%. This improved to 100% at re-audit. However, we found that procedure coding errors remained. We have devised a novel working model to improve all coding issues related to urology.

Conclusion:

It is possible to improve accuracy of coding by educating clinicians working alongside our integrated model of a team of a clinician with an interest in coding with coding and finance personnel.

Total quality management in plastic surgery

BACKGROUND

Quality management in plastic surgery has been limited to audit reports of individual clinical conditions, procedures and their outcomes, mortality rates, or other individual aspects of the field.

METHODS

This work was done as a part of the mission assigned to us from the Military Medical Directorate to work on and develop the policies and standards of the practice of plastic surgery in the Saudi military hospitals. It is an overview of auditing in plastic surgery with a new expansion vision of the concept of total quality management in plastic surgery including the executable component (new data collection forms) that leads to the complete quality cycle. In addition, a pilot study over one of the main referral units of the military hospitals, Riyadh Armed Forces Hospital, is included.

RESULTS

The various suggested audit and the monthly report forms are presented. The study of the unit revealed that the most frequently operated region was the head and neck, followed by the hand. Major operations constituted 31.3% of the surgeries done, and there was an overall negative correlation between age and hospital stay.

CONCLUSIONS

A general approach and unifying the auditing process facilitates comparisons between departments in the same country and between different countries in the globe.

Audit of clinical coding of major head and neck operations

INTRODUCTION

Within the NHS, operations are coded using the Office of Population Censuses and Surveys (OPCS) classification system. These codes, together with diagnostic codes, are used to generate Healthcare Resource Group (HRG) codes, which correlate to a payment bracket. The aim of this study was to determine whether allocated procedure codes for major head and neck operations were correct and reflective of the work undertaken. HRG codes generated were assessed to determine accuracy of remuneration.

PATIENTS AND METHODS

The coding of consecutive major head and neck operations undertaken in a tertiary referral centre over a retrospective 3-month period were assessed. Procedure codes were initially ascribed by professional hospital coders. Operations were then recoded by the surgical trainee in liaison with the head of clinical coding. The initial and revised procedure codes were compared and used to generate HRG codes, to determine whether the payment banding had altered.

RESULTS

A total of 34 cases were reviewed. The number of procedure codes generated initially by the clinical coders was 99, whereas the revised codes generated 146. Of the original codes, 47 of 99 (47.4%) were incorrect. In 19 of the 34 cases reviewed (55.9%), the HRG code remained unchanged, thus resulting in the correct payment. Six cases were never coded, equating to pound15,300 loss of payment.

CONCLUSIONS

These results highlight the inadequacy of this system to reward hospitals for the work carried out within the NHS in a fair and consistent manner. The current coding system was found to be complicated, ambiguous and inaccurate, resulting in loss of remuneration.

Computerisation, coding, data retrieval and related attitudes among Swedish general practitioners-a survey of necessary conditions for a database of diseases and health problems

OBJECTIVE

To investigate necessary conditions for the establishment of a database of diseases and health problems for research and health care planning, based on electronic patient records in everyday clinical use among general practitioners (GPs).

DESIGN

Postal questionnaire study.

SETTING

Primary health care in Sweden.

SUBJECTS

Three hundred randomly selected GPs.

MAIN OUTCOME MEASURES

Degree of computerisation of patient records. User frequency and characteristics of diagnosis classification systems and coding tools. Frequency of coding activities and retrieval of codes, and related attitudes. Opinions on a primary health care version of ICD-10.

RESULTS

A total of 184 GPs (61% of the 300 GPs) were included in the study. About 92% used an electronic record system, some type of diagnostic classification was used by 93%, and ICD based classifications by 88%. The classification in use was computerised for 74%. Mainly simple tools were used to retrieve diagnostic codes. About 76% of GPs reported classifying at least one symptom or disease per encounter. The codes were retrieved 'once a month' or more by 19%. Classification of diseases was considered important for follow-up by 83%, and for the care of the patient by 75% of the GPs. The primary health care version of ICD-10 with a total of 972 codes was considered too limited in size by 31%.

CONCLUSION

Electronic patient records in everyday clinical use in Swedish general practice provide several fundamentals for a database of diagnostic data. However, there are several barriers to the establishment of such a database that is both valid and reliable.

Coding plastic surgery operations: an audit of performance using OPCS-4

Accurate coding is essential for local and national data reporting and for contracting. It is also integral to clinical governance. This study aimed to assess the accuracy of coding in Morriston Hospital plastic surgery theatres and coding office, to reaudit and address poor practice. A third coding system, a computerised logbook developed by the senior author, was not analysed in this study. Fifty operations coded using OPCS-4 were compared with a gold standard for overall accuracy, primary and procedural codes. Results were discussed with all relevant staff and reaudit took place 3 months later. The data were analysed using the paired Student's t -test for intergroup comparisons and the unpaired test for intragroup assessment. At initial audit, the coding office was significantly better than theatre staff in overall accuracy (78% vs 43% respectively P<< 0.01) and in procedural codes (98% vs 42%, P<< 0.01) but there was no difference in primary codes (62% vs 74%). At reaudit the only significant improvement was in overall accuracy of coding office records, although the clinical coders were now significantly better at recording primary codes than theatre staff (76% vs 56%, P< 0.05). The conclusions were that the quality of coding in theatre was poor and should stop. Clinical coders performed better but 1/3-1/4 of essential codes were inaccurate. This may have been due to limited understanding of terminology and techniques, difficulty reading operation notes and complexity of OPCS-4. Recommendations included closer cooperation between surgeons and coders to support and improve clinical coding performance.

Accuracy of centrally recorded OPCS codes for vascular surgery in the United Kingdom

AIM

Centrally recorded OPCS codes are based upon district returns. The aim of this study is to determine the accuracy of this system with regard to vascular surgery.

METHODS

Prospectively recorded audit data for vascular and endovascular procedures were compared with those obtained from the Department of Health and Welsh Office. Five U.K. hospitals were involved in the study. Data were obtained for the twelve months, 1 April 1994-30 March 1995 (these being the most up to date figures available).

RESULTS

The total number of arterial reconstructions based on audit data was 1082. Those recorded by the OPCS codes were 743. This represents a discrepancy of -31.3% (range for the five hospitals: -13.1% to -63.8%). When examining specific codes similar discrepancies were seen. For example, in one hospital 38 AAA repairs were carried out but only two were centrally recorded. However, examination of ICD9 codes (relating to hospital admissions) for that hospital showed that 38 patients with AAA were admitted. A similar wide variation was seen when examining iliac and superficial femoral artery endovascular procedures. Despite the discrepancies of audit and OPCS data, the codes for reconstructions did reflect relative workload of the different hospitals.

CONCLUSION

This study shows that there is a marked underestimate of vascular workload when comparing central recorded data with that obtained from local audit. Marked variation is seen in the accuracy of data submitted from different hospitals.

Survey of changes in the provision of vascular surgical services in the Oxford Region over 5 years

AIM

This study aimed to examine changes in the provision of vascular services in the Oxford region over 5 years.

METHODS

A questionnaire was sent to all general surgeons in the region asking of their involvement in vascular surgery. Data were obtained from the Department of Health concerning vascular procedures and inpatient codes for each district in the Oxford Region from 1990-1991 to 1994-1995. Office of Population Censuses and Surveys (OPCS) data for abdominal aortic aneurysm repair and femoral artery reconstruction were validated against data collected prospectively for West Berkshire.

RESULTS

Eighteen of 45 surgeons who replied to the questionnaire carried out elective and emergency arterial work. All were members of the Vascular Surgical Society of Great Britain and Ireland (VSS). All but one took part in the general surgical rota. Eight surgeons carried out emergency arterial surgery only; only two of these were members of the VSS. Of 19 surgeons undertaking no arterial surgery, 15 operated on primary and 11 on recurrent varicose veins. The number of arterial reconstructions rose from 20.8 per 100000 population to 28 per 100000 throughout the study. The greatest increase occurred in districts where a new vascular consultant had been appointed. Similar results were obtained with endovascular procedures. The number of major amputations remained fairly constant at approximately 11 per 100000 population. The number of inpatient episodes for arterial disease also rose, from 35.7 to 47.6 per 100000. In validating OPCS codes against prospectively collected data, discrepancies for individual years were noted but the annual trend was reflected fairly accurately by the codes.

CONCLUSION

There has been an increase in vascular activity in the region, but variations still exist between different districts.

Can hospital discharge diagnoses be used for intensive care unit administrative and quality management functions?

OBJECTIVE

To determine whether hospital discharge diagnoses can be used for intensive care unit (ICU)-related activities.

DESIGN

Comparison between the diagnoses coded by physicians at the time of ICU admission and those diagnoses coded by medical records personnel.

SETTING

University hospital adult surgical ICU.

PATIENTS

Consecutive ICU admissions (n = 622).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The ICU admission and hospital discharge codes were compared in two ways. Initially, each discharge code was subtracted from the corresponding ICU admission code. There was no difference in 150 (24%) cases. In 216 (35%) patients, the codes differed by +/-10. In 221 (36%) instances, the codes differed by >200. The secondary discharge diagnoses were also compared with the ICU admission diagnoses. In 56 patients, the ICU admission diagnosis was one of the secondary diagnoses. The second comparison involved having two physicians not associated with the study examine each pair of codes to determine if the two diagnoses were medically different. Review of the codes by physicians not involved in the study found that in 318 (48%) patients, the two diagnoses were not different, i.e., the codes were either the same or the codes were so similar as not to functionally change the actual diagnosis.

CONCLUSIONS

The primary discharge diagnosis often failed to reflect the reason for ICU admission, making it impossible to consistently establish the reason for ICU admission from the discharge data. The reason for ICU admission was also frequently not included among the secondary discharge diagnoses. Administrative data are therefore not useful for ICU quality management and other functions. Intensivists need to establish their own databases.