Increasing the accuracy of operative coding

Development of a New Knee Arthroscopy Operative Proforma Saving Thousands of British Pounds

Coding inaccuracies in documentation of surgical procedures misrepresent the productivity of departments, with harmful fiscal consequences and detract from effective clinical governance. We aimed to assess the extent of this within our centres.  We retrospectively analysed the operative records of 34 patients from two centres over a period of a month, undergoing varying arthroscopic knee operations. We found that 50% of cases had incorrect coding for procedures performed. On review of the clinical coding, the loss of payment summed up to £29,325.  The flawed coding practices stemmed from the heterogeneity and convolution in documentation of procedures. Our intervention was the development of a multi-faceted arthroscopic operation note proforma, centred on concise documentation for appropriate codes to be gleaned. We re-audited our new proforma, retrospectively collating data on 37 patients over a period of five months undergoing arthroscopic knee procedures. We found only 5% of cases were coded incorrectly, summing to a loss in tariff payment of £2654.  In conclusion, poor quality of documentation and written communication between surgical and coding departments can have drastic ramifications for funding. An active refinement of this process can ultimately help to provide more resources for improved patient care.

Surgeon involvement in clinical coding to improve data accuracy and remuneration in a shoulder and elbow unit

BACKGROUND

Clinical coders are dependent on clear data regarding diagnoses and procedures to generate an accurate representation of clinical activity and ensure appropriate remuneration is received. The accuracy of this process may potentially be improved by collaboration with the surgical team.

METHODS

Between November 2017 and November 2019, 19 meetings took place between the Senior Clinical Fellow of our tertiary Shoulder & Elbow Unit and the coding validation lead of our Trust. At each meeting, the Clinical Fellow assessed the operative note of cases in which uncertainty existed as to the most suitable clinical codes to apply and selected the codes which most accurately represented the operative intervention performed.

RESULTS

Over a 24-month period, clinical coding was reviewed in 153 cases (range 3-14 per meeting, mean 8). Following review, the clinical coding was amended in 102 (67%) of these cases. A total of £115,160 additional income was generated as a result of this process (range £1677-£15,796 per meeting, mean £6061). Only 6 out of 28 (21%) cases initially coded as arthroscopic sub-acromial decompressions were correctly coded as such.

DISCUSSION

Surgeon input into clinical coding greatly improves data quality and increases remuneration received for operative interventions performed.

Clinical coding and data quality in oculoplastic procedures

INTRODUCTION

Hospitals in England are reimbursed via national tariffs set out by NHS England. The tariffs payable to hospitals are determined by the activity coded for each patient's hospital visit. There are no national standards or publications within oculoplastics for coding accuracy. Our audit aimed to determine the accuracy of coding oculoplastic procedures carried out in theatres and to assess the financial implications of any discrepancies.

METHODS

We carried out a prospective audit of consecutive oculoplastic procedures performed at one hospital site over a 6-week period. We subsequently created a coding proforma and performed a re-audit using the same methods.

RESULTS

In the first cycle, clinical coding was 'correct' in 30.7% of cases, 'incomplete' for 12.9% and 'incorrect' for 56.5%. Of the 'incorrect' codes, 54.3% were coded as non-oculoplastic procedures (e.g. extraocular muscle surgery). We discussed our findings with the coding team in order to address the sources of error. We also created a 'tick box' coding proforma, for completion by surgeons. Our re-audit results showed an improvement of 'correct' coding to 85.7%.

CONCLUSION

Clinical coding is complex and vulnerable to inaccuracy. Our audit showed a high rate of coding error, which improved following collaboration with our coding team to address the sources of error and by creating a coding proforma to improve accuracy. Accurate clinical coding has financial implications for hospital trusts and consequently Clinical Commissioning Groups. In times of severe financial pressures, this could be a valuable tool, if rolled out over all specialities, to make much needed savings.

The effect of template-based sequential (TBS) coding on an NHS plastic surgical practice

INTRODUCTION

Clinical coding is often a mystery to us surgeons, but in actuality, it has a huge bearing on the financial sustainability of our services. Given the rapid innovations in plastic surgical procedures, clinical coders often struggle to decipher the extent of surgery. Meeting midway is the way forward here.

METHODS

In a prospective audit over a six-month period, we analysed data from 2586 patients in our practice: a combination of general plastic surgery and specialist facial reanimation services. This involved comparing data from the first three months where coding was performed by clinical coders based on operating notes per se (phase I) and the subsequent three months when the operating surgeon filled in the OPCS 4.7 (version 2014) codes at the time of completing the operating notes; the clinical coders then vetted this information (phase II) as part of a sequential TBS coding system.

RESULTS

In terms of outpatient income, there was a 3% increase in facial palsy income and 6% increase in general plastic services, but the most significant improvement was in terms of procedural income per case. General plastic surgery cases saw an increase of 49%, while facial palsy income increased by 58% over the same period. Greater insight into OPCS and HRG codes also allowed for the calculation of the actual tariffs for specific procedures.

CONCLUSIONS

Having the operating surgeon as the primary coder, using a template, with subsequent vetting by the clinical coders, improves data capture, and this in turn increases income. Future recommendations include the use of proforma-based operating notes for workhorse procedures.

Coding in surgery: impact of a specialized coding proforma in hepato-pancreato-biliary surgery

BACKGROUND

Coding inaccuracies in surgery misrepresent the productivity of hospitals and outcome data of surgeons. The aim of this study was to audit the extent of coding inaccuracies in hepato-pancreato-biliary (HPB) surgery and assess the financial impact of introducing a coding proforma.

METHODS

Coding of patients who underwent elective HPB surgery over a 3-month period was audited. Codes were based on International Classification of Diseases 10 and Office of Population and Census Surveys-4 codes. A coding proforma was introduced and assessed. New human resource group codes were re-assigned and new tariffs calculated. A cost analysis was also performed.

RESULTS

Prior to the introduction of the coding proforma, 42.0% of patients had the incorrect diagnosis and 48.5% had missing co-morbidities. In addition, 14.5% of primary procedures were incorrect and 37.6% had additional procedures that were not coded for at all. Following the introduction of the coding proforma, there was a 27.5% improvement in the accuracy of primary diagnosis (P < 0.001) and 21% improvement in co-morbidities (P = 0.002). There was a 7.2% improvement in the accuracy of coding primary procedures (P = not significant) and a 21% improvement in the accuracy of coding of additional procedures (P < 0.001). Financial loss as a result of coding inaccuracy over our 3-month study period was £56 073 with an estimated annual loss of £228 292.

CONCLUSION

Coding in HPB surgery is prone to coding inaccuracies due to the complex nature of HPB surgery and the patient case-mix. A specialized coding proforma completed 'in theatre' significantly improves the accuracy of coding and prevents loss of income.

Hospital-wide implementation of an electronic-workflow solution aiming to make surgical practice improvement easy

BACKGROUND

In measuring quality of health-care delivery, digital infrastructure is essential. The aim at this tertiary centre was to create a hospital-wide workflow system that collected data prospectively as part of daily practice.

METHODS

In moving towards an electronic health record, a hospital-wide integrated workflow system was introduced in 2013, which electronically managed the perioperative patient journey while simultaneously facilitating surgical audit. Analysis of its implementation was carried out presenting early outcomes using general surgery as an example.

RESULTS

Theatre-bookings (44 953) were made with compliance approaching 90% for all services. Of 7179 general surgical operations over 24 months, 5785 (80%) had an operation note created using the new system. Cumulative summation of uptake of synoptic operative reporting (SOR) for laparoscopic cholecystectomy (LC) was 81% with documentation being superior in terms of antibiotic use and steps to safe cholecystectomy (P < 0.001). A LC SOR took 4 min to complete (interquartile ranges 2-5 min, n = 425) and was immediately available on the day of surgery compared to narrative operative reports taking 2 days (interquartile ranges 1-5 days, n = 174) (P < 0.001). From July 2014 to November 2015, 557 (10%) complications were recorded for 5749 general surgical operations with 99% of complications being reviewed.

CONCLUSION

The rapid and sustained uptake of both theatre-bookings and SOR likely reflect high end-user satisfaction with the system. Service metrics indicate a significant improvement in the time of delivery. The ability to seamlessly complete the audit cycle at an individual, department and hospital level has been achieved.

The accuracy of real-time procedure coding by theatre nurses: a comparison with the central national system

Accurate and timely clinical data are required for clinical and organisational purposes and is especially important for patient management, audit of surgical performance and the electronic health record. The recent introduction of computerised theatre management systems has enabled real-time (point-of-care) operative procedure coding by clinical staff. However the accuracy of these data is unknown. The aim of this Scottish study was to compare the accuracy of theatre nurses' real-time coding on the local theatre management system with the central Scottish Morbidity Record (SMR01). Paired procedural codes were recorded, qualitatively graded for precision and compared (n = 1038). In this study, real-time, point-of-care coding by theatre nurses resulted in significant coding errors compared with the central SMR01 database. Improved collaboration between full-time coders and clinical staff using computerised decision support systems is suggested.

Reliability of clinical coding of hip facture surgery: implications for payment by results?

In our hospital all operative procedures are coded using the OPCS 4.3 classification and in addition are entered into an independent theatre databases. Using these two databases we identified patients undergoing hip fracture surgery at this hospital between 1st November 2003 and 30th November 2006. We identified 408 cases. No single database identified all 408 cases. A quarter of cases (N=98) were not procedurally coded. Only 43.2% (N=176) of cases were recorded in both the theatre database and procedurally coded at the time of this study. Overall the coding accuracy of these 176 cases was 93.8%. Clinical coding at this hospital was unreliable and inaccurate, which has major implications for national statistics, performance analysis and most importantly Payment by Results. We discuss this further and offer possible solutions to improve the coding process.

Evaluation of factors influencing accuracy of principal procedure coding based on ICD-9-CM: an Iranian study

To evaluate the accuracy of procedural coding and the factors that influence it, 246 records were randomly selected from four teaching hospitals in Kashan, Iran. "Recodes" were assigned blindly and then compared to the original codes. Furthermore, the coders' professional behaviors were carefully observed during the coding process. Coding errors were classified as major or minor. The relations between coding accuracy and possible effective factors were analyzed by chi(2) or Fisher exact tests as well as the odds ratio (OR) and the 95 percent confidence interval for the OR. The results showed that using a tabular index for rechecking codes reduces errors (83 percent vs. 72 percent accuracy). Further, more thorough documentation by the clinician positively affected coding accuracy, though this relation was not significant. Readability of records decreased errors overall (p = .003), including major ones (p = .012). Moreover, records with no abbreviations had fewer major errors (p = .021). In conclusion, not using abbreviations, ensuring more readable documentation, and paying more attention to available information increased coding accuracy and the quality of procedure databases.

The Risk and Consequences of Clinical Miscoding Due to Inadequate Medical Documentation: A Case Study of the Impact on Health Services Funding

As coded clinical data are used in a variety of areas (e.g. health services funding, epidemiology, health sciences research), coding errors have the potential to produce far-reaching consequences. In this study the causes and consequences of miscoding were reviewed. In particular, the impact of miscoding due to inadequate medical documentation on hospital funding was examined. Appropriate reimbursement of hospital revenue in the casemix-based (output-based) funding system in the state of Victoria, Australia relies upon accurate, comprehensive, and timely clinical coding. In order to assess the reliability of these data in a Melbourne tertiary hospital, this study aimed to: (a) measure discrepancies in clinical code assignment; (b) identify resultant Diagnosis Related Group (DRG) changes; (c) identify revenue shifts associated with the DRG changes; (d) identify the underlying causes of coding error and DRG change; and (e) recommend strategies to address the aforementioned. An internal audit was conducted on 752 surgical inpatient discharges from the hospital within a six-month period. In a blind audit, each episode was re-coded. Comparisons were made between the original codes and the auditor-assigned codes, and coding errors were grouped and statistically analysed by categories. Changes in DRGs and weighted inlier-equivalent separations (WIES) were compared and analysed, and underlying factors were identified. Approximately 16% of the 752 cases audited reflected a DRG change, equating to a significant revenue increase of nearly AU$575,300. Fifty-six percent of DRG change cases were due to documentation issues. Incorrect selection or coding of the principal diagnosis accounted for a further 13% of the DRG changes, and missing additional diagnosis codes for 29%.The most significant of the factors underlying coding error and DRG change was poor quality of documentation. It was concluded that the auditing process plays a critical role in the identification of causes of coding inaccuracy and, thence, in the improvement of coding accuracy in routine disease and procedure classification and in securing proper financial reimbursement.

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.