Clinical CodingPaula Wheeler, ACC

Clinical Coding Service Manager

What is Clinical Coding?

Translation of medical terminology written by a clinician to describe a patient’s:

Complaint

Problem

Diagnosis

Treatment

Reason for seeking medical attention

into a coded format which is nationally and internationally recognised

CLASSIFICATION CODING

The classifications used by this Trust for clinical coding are:

• ICD10 International Classification• Used to capture diagnostic clinical data• OPCS4 a UK specific classification• Used to capture surgical interventions and

procedures

Why do we code?

Clinical

Statistical

Clinical audit

Outcome

measurement

Cost analysis

Clinical Governance

ClinicalIndicators

Commissioning

Financial flows HRGs & PbR

Health trends

Informatio

n

Governanc

e

Epidemiology

Aetiology Casemix planning

Treatment effectiveness

Benchmarking

3 Languages of Health

• Terming

• Coding

• Grouping

SOURCE DOCUMENTATIONThe coding source documentation should be:

Accurate and complete

Avoid use of abbreviations

Clear and detailed

Legible and in indelible ink or typed

Reflect the patients episode of care

Co-morbiditiesThe hospital episode length of stay and co-morbidities can

affect the HRG allocation.• Epilepsy• Diabetes• Asthma• Hypertension• Heart conditionsRecently published guidance list of all co-morbidities that

must be coded when mentioned in the clinical record

Financial impact of Incomplete terming

• R00.2 (ICD10) Palpitations

• HRG 2015-2016 EB07I

• Arrhythmia or conduction disorders, without CC

• Tariff £617

Complete terming

• R00.2 (ICD10) Palpitations

• E11.9 (ICD10) Type 2 diabetes

• HRG 2015-2016 EB07H

• Arrhythmia or conduction disorders, with CC

• Tariff £1,695

Terming

R04.0 (ICD10) EpistaxisE05.1 (OPCS)Cauterisation of internal

noseHRG 2015-2016 CZ12YMinor Nose Procedures 19 years and

over without CCTariff £719

Be specific

• R04.0 (ICD10) Epistaxis

• E05.2 (OPCS) Ligation of artery of internal nose

• HRG 2015-2016 CZ15Q

• Complex Major Nose Procedures without CC

• Tariff £2,975

BENEFIT OF RICHER CODING

Finance InformationResearchCancer registry

Everyone benefits

Clinical Coding ContactsPaula Wheeler , Clinical Coding Service ManagerJo Counter, Clinical Coding Training ManagerAnn Buttle, Clinical Coding Data Analyst & AuditorMargaret Caldaralo, Team LeaderDaniel Whittaker, Team LeaderRichard Gale, Clinical Coding Auditor

Thank You

Any Questions?