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A stack of paper medical records on desk

The Clinical Coding team play a vital role in making sure we get paid for what we do.

Every procedure and diagnosis recorded in a patient's notes needs to be classified according to the OCPS or ICD coding framework. This is then put on PAS and means the data can be used for our financial reporting.

 

Clinical Coders

Clinical coders investigate discharged patient's case notes, extract diagnostic and procedural information, and translate into nationally agreed codes that underpin NHS Trust's reimbursement process. Clinical coding is vital for the Trust's financial viability as no coding or late coding results in no funding & incorrect or incomplete coding leads to either under or over payment. Coding also provides high quality data for clinicians which ensures better and safer patient care.

The coders need to meet a monthly deadline, whereby they have to have coded all of the previous month's discharges. If this is not met, the Trust will not be paid for any of the uncoded activity.

Accuracy of coding is at risk without all of the appropriate information i.e. fully informed case notes, operation notes etc. Therefore it is vital that the coders have:

  • Timely dispatch of all case notes from wards to coding office
  • Detailed, legible diagnostic & procedural notes recorded in health records
  • Full Discharge Summaries

 

In recent years there has been a massive expansion in the use of clinical coded data, which includes;

  • Information about the quality and safety of hospital services
  • Effectiveness of care
  • Enhancing Quality Pathways data
  • Standardised hospital mortality data

 

Clinical coding is a highly skilled task that requires considerable training and extensive knowledge. There is a National Clinical Coding Qualification (NCCQ). The examination requires very high standards, therefore Trusts usually need to invest at least two to four years in each new recruit to ensure they reach the required standard before attempting the examination. At present we have six ACCs (nationally accredited coders).

 

Clinical Coding Auditor

The regular clinical coding audit provides the team with the necessary information to achieve continuous quality improvement resulting in a robust data quality cycle. The audit cycle is a crucial part of the assurance framework required for Payment by Results and Information Governance Toolkit.

The Code of Practice for auditors has been endorsed by the Audit Commission stating "it puts robust safeguards into the audit process to preserve impartiality".

 

Data Input Clerk

This role is responsible for the accurate input of procedural codes into PAS from Outpatient attendance Forms in order to support Payment by Results for OPD activity.

Other duties include collection of outstanding casenotes for coding from wards and other Trust areas so that the Coding Team can achieve monthly CCG billing targets.

For more information about clinical coding, please click here.

 

Why coding matters for non-coders

Coded clinical data (generated from classifications OPCS-4 and ICD-10) uses rules and conventions that, when applied accurately result in the provision of high quality statistically meaningful data. This directly affects:

  • Clinicians and all healthcare professionals - as the coders now record in greater detail the activity in Trust.
  • Financial teams - as the coded clinical data is grouped to meet the reporting structure of Payment by Results to ensure the Trust is paid accurately for activity.
  • Information managers and data analysts - to support service planning and delivery decisions
  • IT professionals - as the execution of the national programme for IT and improved classifications requires their collaborative working with clinicians and coders to effectively implement necessary system upgrades.