Royal National Orthopaedic Hospital NHS Trust · Royal National Orthopaedic March ... • The state of some of the case notes is of concern and raises ... This will be revised and

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Royal National Orthopaedic March 2008

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Royal National Orthopaedic Hospital NHS Trust

EXTERNAL CLINICAL CODING AUDIT

for the

PAYMENT BY RESULTS DATA ASSURANCE FRAMEWORK

11th February – 14th February 2008

FINAL REPORT

Auditors: Christine Sweeting ACC Hon (Lead Auditor and Author)

NHS CfH Accredited Auditor

Melanie Holmes ACC

NHS CfH Registered Auditor

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Contents Page

Executive summary 3

Introduction 7

Background to PbR data assurance external audit 7

Aims 8

Objectives 8

Methodology 8

Trust Background 9

General Findings 11

Trauma and Orthopaedics 13

Paediatric 15

Trauma and Orthopaedics CH R HRG 16

Trauma and Orthopaedics HRG H22 17

Conclusions 18

Recommendations 19

Appendix A Error Key definitions 21

Appendix B Analysis sheets 26

Appendix C Action Plan 36

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Executive summary

Introduction

This report presents a summary of the main findings of the external Clinical Coding audit undertaken at Royal National Orthopaedic Hospital Stanmore, as part of the Audit Commission’s Payment by Results data assurance framework in 2007/08.

Audit approach

For the external Clinical Coding audits undertaken for PbR data assurance, 280 FCEs have been audited using the latest version of the national NHS Connecting for Health Clinical Coding Audit Methodology Version 3.

180 (100 (paediatric surgery 171), 50 (HRG Ch R spinal surgery and primary spinal conditions 110) and 30 (HRG Ch H22 minor procedures to the musculoskeletal system) of the FCEs were selected from an area targeted using a benchmarking process based on an analysis of Trust data submitted to the Secondary Uses Service (SUS). The remaining 100 were based on a national theme (Trauma and Orthopaedics (110).

The specialty HRG Ch R spinal surgery and primary spinal conditions had been highlighted as a potential area for concern as many of these episodes of care were extremely complex and required a significant amount of time to be allocated for the audit process. After discussions between Andrew Wheeler, Head of Clinical Coding and Clinical Data Quality, Christine Sweeting Lead Auditor acting on behalf of D and A Consultancy and Donna Pannell and Peter Saunders PbR team Audit Commission it was agreed that the target area of 70 episodes could be reduced. This resulted in 50 out of 70 episodes being audited.

The audit also reviewed issues around data definitions and identified any examples of best practice.

Main findings

The accuracy rate overall was 88.93% of primary diagnoses and 98.40% of secondary diagnoses correct. For procedures coding, 98.54% primary procedures and 96.09% of secondary procedures were correct. The number of episodes with errors which would have changed the HRG was 1 representing 0.36% of the total.

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Table of main findings

Specialty %Primary diagnoses

correct

% Secondary diagnoses

correct

% Primary procedures

correct

% Secondary procedures

correct

% of episodes changing

HRG

Overall

88.93

98.40

98.54

96.09

0.36

Benchmarked area –(171 paediatric surgery Broad)

89.00

98.14

98.98

96.37

0.00

Medium – (110 Trauma and Orthopaedics – HRG Ch R spinal)

98.00

98.43

100.00

94.39

0.00

Focused – (110 – Trauma and Orthopaedics HRG H22)

90.00

98.33

96.67

88.52

0.00

Themed area –(110 – Trauma and Orthopaedics)

84.00

98.60

97.94

100.00

1.00

These are excellent figures for coding accuracy and reflect the dedication and expertise of the Clinical Coding Department. There was just one repeated error that accounted for the slightly lower figure in orthopaedics themed area.

• There are strong collaboration links already forged between the Clinical Coding Department and Clinicians and this ongoing relationship is vital to support accurate coding for Payment by Results.

• The state of some of the case notes is of concern and raises potential issues for patient safety – particularly in trying to find relevant notes for designated specialties. Histology and Pathology reports were often misfiled and detailed summary reports were not present across all specialties covered in the audit. Additionally the sheer bulk and weight of the notes especially for spinal surgery needs to be addressed with notes split into more manageable volumes.

• Some of these findings were also recorded in the last external audit report carried out by NHS Connecting for Health London in June 2005 and do not appear to have been fully acted upon.

• The following conclusions and recommendations provide more detail to support these main findings as follows:

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Conclusions

� The state of the some of the clinical case notes is of concern and may compromise patient safety.

� There is a high level of commitment from the Head of Clinical Coding and Clinical Data Quality who has responsibility for Clinical Coding, Clinical Coding staff and respective line management in striving to enhance the Clinical Coding function for the Trust.

� The Clinical Coding team are hugely experienced in their specialist field and this is reflected in the high accuracy achieved at this Trust.

� Regular quarterly internal audit is currently undertaken and the intention is that this will be further enhanced by the Head of Clinical Coding. This will provide further support for Information Governance and data quality issues.

� There is already a comprehensive Policy and Procedure document that is still in the process of being fully implemented for the Clinical Coding department. This will be revised and brought up to date to reflect locally agreed codes from Clinicians including sign off and relevant national standards.

� It is apparent however, that for this Trust which carries out very complex spinal procedures, Chapter V in OPCS.4.4 is still lacking many relevant codes to support modern day techniques for spinal surgery to fully support HRG allocation – many procedures for spinal surgery are outside of the HRG tariff and are agreed at a local level.

� Strong links have been forged with Clinicians which will be of increasing importance for Payment by Results and implementation of HRG version 4.

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Recommendations

Complete, accurate and timely coded clinical data has always been essential in providing information for statistics, epidemiology, managers and clinical audit and now more so for financial purposes. The degree of success in achieving this is dependent on all of those in the process having an understanding of what is required by all parties. The Head of Clinical Coding and Clinical Data Quality and the Clinical Coding Department at the Royal National Orthopaedic Hospital are committed to and are achieving high quality clinical coded data.

A couple of the recommendations from the last external Clinical Coding audit in June 2005 still need to be attended to and are further re-iterated in this report as follows:

� Some urgent reappraisal of the current state of the case notes. This should include the downsizing of some volumes, efficient filing of histology/pathology reports and correct specialty divisions being maintained.

� The continuation of quarterly internal audit is recommended, as it should help to identify any potential training or information issues. Additionally every Clinical Coder should have some training at a minimum every 2 years including refresher training.

� Continue to support the excellent liaison between Clinicians and the coding department, especially in furthering the internal audit process. The involvement of Clinicians in the coding process should highlight to them the requirement to provide completeness and depth for assigning accurate coding within the written case notes and discharge summaries.

� Continuing current budget allocation to support the above recommendations. As Payment by Results and correct HRG allocation become increasingly important to both the Trust and their relevant PCT and Commissioning Groups, ensuring that adequate allowance for training and attendance at workshops/ conferences has been made is vital.

� Liaise with other orthopaedic specialist Trusts to form a cohort. The review of current coding practice in spinal surgery in particular is recommended as the limitations of OPCS.4.4 for these procedures may result in differing assignment of codes and may indicate further input required for OPCS.4.5

Benchmark Report

It is hardly surprising that the benchmarked data for this Trust threw up higher than average mean diagnoses per spell. The complexity of the case mix for specialist hospitals will undoubtedly increase this marker. This will also be the case for mean excess days and mean complication. Specialist Trusts do not easily stand comparison with other NHS Trusts whose case mix is fundamentally different. It would be far more useful to compare ‘like with like’ e.g. form a cohort of specialist orthopaedic Trusts e.g. RNOH, Stoke Mandeville, Oswestry etc.

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Introduction

There is wide recognition in the National Health Service (NHS) of the importance of good quality coded clinical data and the fundamental role it plays in the management of hospitals and the commissioning of services for the population.

With the introduction of the new NHS financing regime, Payment by Results (PbR), this importance has increased, as it has a major influence on the payment that providers receive. Recorded diagnoses, using International Statistical Classification of Diseases and Related Health Problems – tenth revision (ICD10) and procedures, using Office of Population and Censuses and Surveys- fourth revision (OPCS4) are key determinants of the Healthcare Resource Group (HRG) to which each patient is assigned, and hence the tariff which is applied. Poorly coded data can result therefore in inaccurate HRG assignment and inaccurate payments.

The fourth revision of OPCS4 was totally rewritten during 2005 and issued in April 2006 as OPCS 4.3; which was in turn reviewed and revised as necessary during 2006/07 to produce OPCS4.4. These revisions over the last two years have increased the number of procedure codes to better record clinical interventions and procedures independent of setting.

Background to PbR data assurance external audit

The Audit Commission has worked with the Department of Health to develop a Payment by Results Assurance Framework to support the accuracy of payments and improvements in data quality. The programme is being rolled out in 2007/08, following successful piloting during 2006/07 at acute Trusts and Primary Care Trusts (PCTs) in two Strategic Health Authority (SHA) areas.

The core component of the programme in 2007/08 is an independent, external Clinical Coding audit programme at all NHS acute Trusts, including Foundation Trusts, in England, undertaken by experienced, registered and accredited Clinical Coding Auditors.

This external Clinical Coding audit is part of this framework where all Trusts will be independently audited, guided by the national benchmarking data. This benchmarking data compares providers against their peers for a set of indicators and identifies anomalies which may signal data quality issues and which warrant further investigation via audit.

This audit was undertaken as part of the PbR assurance framework. The Clinical Coding audit looked at a random sample of 280 FCEs constituting complete spells, covering Trauma and Orthopaedics (100) Paediatric Orthopaedic Surgery (100) Trauma and Orthopaedics HRG Chapter R (50) it should be noted here that prior permission was granted from the Audit Commission to curtail this number as appropriate due to the complexity of coding for these spinal procedures. 50 out of the 70 were audited, and Trauma and Orthopaedics HRG Chapter H22 Minor procedures to the musculoskeletal system (30) during the period July – September 2007.

180 of the FCEs were selected from an area targeted using a benchmarking process based on an analysis of Trust data submitted to the Secondary Uses Service (SUS). The remaining 100 were based on a national theme (Trauma and Orthopaedics).

The audit was undertaken by Christine Sweeting ACC and Melanie Holmes ACC from D and A Consultancy Ltd, working on behalf of the Audit Commission.

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Aims

The audit aims to:

� Provide commissioners with additional assurance on data quality and the accuracy of payments being made to providers under Payment by Results;

� Identify any specific Clinical Coding issues which need to be assessed to further benefit the Trust’s performance; and

� Inform feedback on refinement of the information infrastructure, including national data definitions, standards and coding rules.

Objectives

The specific objectives of the audit are:

1. to assess the accuracy of the Clinical Coding and its impact on casemix;

2. to identify the source of coding errors; and

3. to assess adherence to national standards pertaining to Clinical Coding and data definitions.

Methodology

The audit followed the current version 3 of the Clinical Coding Audit Methodology set out by Connecting for Health, using approved external coding Auditors, with the addition of certain specifics set out by the Audit Commission.

Specific to these audits is the pre-audit set up meeting which takes place several weeks prior to the audit. This is indicated in the guidance documents and is set up by the PCT external Auditor and the PCT. Unfortunately; a pre-audit meeting did not take place for this Trust in spite of repeated attempts by the PCT external Auditor to confirm PCT attendance. Andrew Wheeler Head of Clinical Coding and Clinical Data Quality and Christine Sweeting Lead Clinical Coding Auditor for D and A Consultancy held a teleconference to confirm benchmark data and sought agreement from the Audit Commission to confirm that Chapter R HRG medium area for spinal surgery could be curtailed as appropriate due to the significant complexity of this specialty.

The episodes for audit were drawn randomly from the period June - Sept 2007.

Case notes were provided for the audit covering Trauma and Orthopaedics including spinal surgery HRG Chapter R and HRG Chapter H22 minor procedures to the musculoskeletal system and, Paediatric Orthopaedic Surgery. The themed area was Trauma and Orthopaedics and this was selected based on Trust activity and ensuring an even national coverage rather than through the benchmarking analysis. The other areas were selected through benchmarking analysis drawn from SUS data, highlighting discrepancy between observed and expected activity.

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Trust Background

During the financial year 2006-07 there were 9,300 Finished Consultant Episodes (FCEs) for the Royal National Orthopaedic Hospital, Stanmore. 8,500 FCEs were NHS patients and 500 were private patients.

The Royal National Orthopaedic Hospital is a specialist Orthopaedic Trust that includes a dedicated spinal injuries unit. The vast majority of spells are elective and a significant proportion of patients are tertiary referrals (referred from another hospital).

The Trust implemented OPCS - 4.3 in June 2006 to inform the reference costs in line with DSCN 14/2005 and DSCN 24/2006 and implemented OPCS – 4.4 in April 2007.

The Trust uses the Simplecode clinical encoder which then links to the ICS version 3.7 PAS system. The Clinical Coding department at the Royal National Orthopaedic Hospital is the responsibility of the IM and T Directorate. The Head of Clinical Coding reports to the Director of IM and T. The Head of Clinical Coding has operational and strategic responsibility for the coding function at the Royal National Orthopaedic Hospital.

The Clinical Coding Department consists of a centralised team of three senior Clinical Coders (2.4 WTE) with one combined data quality coordinator and case notes monitor (1 WTE). The department regularly uses an experienced Orthopaedic Coder on the hospital staff bank.

All Clinical Coding is carried out centrally by the team of trained Clinical Coders in a purpose-built office. The Clinical Coding staff are dedicated experienced staff who have been in post some years and hence are on a Band 5 to reflect their degree of skilled knowledge for this complex specialty.

The NHS national standard classifications are used: ICD10 and OPCS4. Clinical terming is not used, although the encoding software does include a clinical terms search facility.

The relevant HRG allocated is available to the Clinical Coders.

Local procedure codes are used for internal and external activity monitoring, waiting list management and theatres activity recording. PACS was implemented at RNOH in 2007. All radiology activity is visible on RIS and approved reports are viewable by Clinical Coders. This is useful to verify dates of certain procedures and investigations and can even help verify whether or not a procedures or investigation has been carried out (if this is unclear from the case notes).

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The department accesses clinical data for coding from the case notes. Other documentation accessed includes histopathology reports on Winpath and theatres-assigned local procedure codes and procedure descriptions on a manual database within the Coding Department to enable further accuracy. All coded information is then input into the Trust PAS system.

There is a deadline for coding to be completed by the fifth working day of the following month. That is, 100% completion for all NHS discharges. Private patients should be coded by the freeze date for each quarter (within one month of the end of each quarter). Clinicians are involved in validating coded data for this specialist Trust, with a strategy in place to regularly present coded clinical data to Clinicians for verification. Internal meetings with coding staff reviewing coding queries and current practice are held once a month by the Head of Clinical Coding as well as attending quarterly meetings with Directorate/ Line Managers. There is a planned training schedule supervised by the Head of Clinical Coding for the department. It includes both internal and external training where applicable. All staff should receive refresher training as appropriate. Regular quarterly internal audits of staff are carried out by the Head of Clinical Coding, with a view to steadily improve the cycle for data quality in line with Information/Clinical Governance. There is a dedicated Clinical Coding budget for training of £2,000 and all staff can attend training/workshop courses as deemed appropriate by the Head of Clinical Coding. The detailed Clinical Coding Policy and Procedure document is kept in the Clinical Coding office. This includes documents detailing training undertaken by the Coders and Coding Clinic inserts amendments to training manual, etc. Further work is in place to significantly enhance this document during 2008.

The last external Clinical Coding audit was carried out in September 2005 by NHS London Connecting for Health and reasonable figures were achieved These figures were based on an audit for Information Governance on 100 episodes.

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General Findings

The source documentation used primarily for most specialties audited is the full case notes which at the point of coding would have an initial discharge letter (and discharge drugs form combined) but will not contain a detailed discharge summary.

The state of the case notes was mixed and not surprisingly for this complex specialty far too bulky in many cases. Some current sets of notes contained information that dated back to 1976. The weight of some sets of notes, especially for spinal surgery must compromise health and safety guidelines. In specialties audited, the ease of finding relevant information was well set out and presented in the paediatric case notes. However, this was not the case for some orthopaedic case notes with a lot of data not filed in relevant chronological order. This will affect time taken by the Clinical Coder to correctly find the relevant episode of care. This was also a finding in the last external audit report carried out in 2005.

The Clinical Coders have access to histology screens and can go back to revise coded data if applicable after reviewing findings.

All errors were reviewed by the Auditors and the Coding Supervisor and agreed.

Benchmark Report

It is hardly surprising that the benchmarked data for this Trust threw up higher than average mean diagnoses per spell. The complexity of the case mix for specialist hospitals will undoubtedly increase this marker. This will also be the case for mean excess days and mean complication. Specialist Trusts do not easily stand comparison with other NHS Trusts whose case mix is fundamentally different. It would be far more useful to compare ‘like with like’ e.g. form a cohort of specialist orthopaedic Trusts e.g. RNOH, Stoke Mandeville, Oswestry etc.

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The overall findings of the audit including were as follows:

Unsafe to audit 0

Total number of episodes audited 280

Number of episodes where HRG affected by error 1 (0.36%)

Primary diagnosis correct 249 (88.93%)

Total number of secondary diagnoses 759

Secondary diagnoses correct 739 (98.40%)

Total number of Primary procedures 274

Primary Procedures correct 270 (98.54%)

Total number of secondary procedures 639

Secondary procedures correct 614 (96.09%)

Only 1 HRG change for this Trust is an excellent result and reflects the high accuracy of coding carried out by this highly specialised team of Coders.

The Coding staff have the advantage of working in a specially designed Coding office and the often highly complex sets of notes have been coded by a team who can take the time to code properly. Hence the high level of accuracy achieved.

It is useful to break the findings in to the specialties looked at i.e. Trauma and Orthopaedics, Paediatric Surgery, Spinal Procedures HRG Chapter R and HRG Chapter H22 Minor procedures to the musculoskeletal system and look at the 1 HRG difference in more detail.

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TRAUMA and ORTHOPAEDICS

Unsafe to Audit 0










These are excellent figures for Trauma and Orthopaedic coding, especially as the only error in primary diagnosis coding was caused by non-adherence to the national standard for coding osteoarthritis patients unless specifically noted by the Clinician to have a primary condition to the .9 unspecified code.

The only other area that is worth mentioning was some diagnostic procedural codes recorded that were not relevant in an in patient setting e.g. X rays and ECG.

There was just 1 HRG Change encountered for this specialty that will be looked at in detail on the following page.

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Example 1 ––in this episode the procedure was not an ‘other specified opening of abdomen’ but rather re-entering at the previous surgical site which has resulted in the HRG change. Additionally, the ECG was not required. ID 29400

Episode Start 17/07/2007 End 20/07/2007

Trust Coding

Audit Coding

Error Key

PDiag T858 Complications of other internal prosthetic devices, implants and grafts - Other complications of internal prosthetic devices, implants and grafts, NEC

T858 Complications of other internal prosthetic devices, implants and grafts - Other complications of internal prosthetic devices, implants and grafts, NEC

Diag2 Z858 Personal history of malignant neoplasm - Personal history of malignant neoplasms of other organs and systems

Z858 Personal history of malignant neoplasm - Personal history of malignant neoplasms of other organs and systems

Diag3 Z860 Personal history of other neoplasms

Z860 Personal history of other neoplasms

Proc1 T308 Opening of abdomen - Other specified

T303 Reopening of abdomen NEC

PP4

Proc2 Y037 Removal of prosthesis from organ NOC

Y037 Removal of prosthesis from organ NOC

Proc3 Z943 Left sided operation Z943 Left sided operation Proc4 U199 Diagnostic

electrocardiography - Unspecified

SPNR

HRG F14 Stomach or Duodenum - Major Procedures <70 or w/o cc

F42 General Abdominal - Very Major or Major Procedures <70 w/o cc

Spell HRG

F14 Stomach or Duodenum - Major Procedures <70 or w/o cc

F42 General Abdominal - Very Major or Major Procedures <70 w/o cc

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PAEDIATRIC SURGERY

Unsafe to Audit 0










Excellent overall figures for this specialty.

The diagnostic coding for this specialty was good with main errors occurring at PDO level with 3 diagnoses overall being omitted.

Secondary diagnoses errors were also mainly at SDO level with 2. There were 6 diagnoses not considered relevant

Procedure coding figures were very accurate with only 1 error in mis - sequencing of a procedure.

Secondary procedure errors were mainly non Coder errors with 4 due to information not being available at the time of coding.

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TRAUMA and ORTHOPAEDICS (CH R HRG)

Unsafe to Audit 0










The diagnostic coding figures were excellent with the only error a non-Coder error due to information not being available to the Coder at the point of coding. Secondary diagnoses were similarly of a high standard with errors at SD3 and SDO level. A degree of over coding was noted with 12 diagnoses not considered relevant. The errors for procedural coding only appeared at a secondary level with 10 secondary procedures omitted and again 8 procedures not considered relevant.

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TRAUMA and ORTHOPAEDICS (HRG H22 minor procedures to the musculoskeletal system)

Unsafe to Audit 0










The main issues with this specialty were at primary diagnosis level and again were not in fact Coder error but non Coder error with no relevant information available at point of coding.

The 1 error at secondary level was due to a 3rd character error.

The 1 primary procedure coding error occurred at 4th character level

Secondary procedure coding highlighted that 5 secondary procedures had been omitted.

These are very good figures overall.

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Conclusions

� There is a high level of commitment from the Head of Clinical Coding and Clinical Data Quality who has responsibility for Clinical Coding, Clinical Coding staff and respective line management in striving to enhance the Clinical Coding function for the Trust.

� There is a dedicated Clinical Coding budget for training, and all staff are able to attend any courses deemed necessary by the Head of Clinical Coding.

� Training is being supplied by local NHS Connecting for Health London but this is not specifically tailored for specialist Trusts.

� The Clinical Coding Department has a centralised team structure already in place

� The Clinical Coding team are hugely experienced in their specialist field and this is reflected in the high accuracy achieved at this Trust.

� Regular quarterly internal audit is currently undertaken and the intention is that this will be further enhanced by the Head of Clinical Coding. This will provide further support for Information Governance and data quality issues.

� There is already a comprehensive Policy and Procedure document that is still in the process of being fully implemented for the Clinical Coding department. This will be revised and brought up to date to reflect locally agreed codes from Clinicians including sign off and relevant national standards.

� At present no staff are actively encouraged to sit for the National Clinical Coding Qualification (NCCQ). The highly specialist nature of the Trust is a major factor and is a limiting element to successful study of the syllabus.

� A couple of training errors have been identified, as OPCS4.3 and 4 have increased their content especially for Chapter W which covers orthopaedic procedures this is not surprising and the Coders are now aware.

� The appropriate use of when to use ICD-10 code Z code Z47.- Other orthopaedic follow-up care needs further consideration with clinical input as current coding is ‘hit and miss’ in assignment as a primary diagnosis.

� It is apparent however, that for this Trust which carries out very complex spinal procedures, Chapter V in OPCS.4.4 is still lacking many relevant codes to support modern day techniques for spinal surgery to fully support HRG allocation – many procedures for spinal surgery are outside of the HRG tariff and are agreed at a local level.

� Some over coding was noted in the audit sample. Most cases contained at least 10 to 13 diagnoses. It is recognised however that many of these will be legitimate to accurately describe the complexity of conditions, and currently there are no national standard guidelines for co-morbidities.

� Strong links have been forged with Clinicians which will be of increasing importance for Payment by Results and implementation of HRG version 4.

� The state of the some of the clinical case notes is of concern and may compromise patient safety.

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Recommendations

Complete, accurate and timely coded clinical data has always been essential in providing information for statistics, epidemiology, managers and clinical audit and now more so for financial purposes. The degree of success in achieving this is dependent on all of those in the process having an understanding of what is required by all parties. The Head of Clinical Coding and Clinical Data Quality and the Clinical Coding department at the Royal National Orthopaedic Hospital are committed to and are achieving high quality clinical coded data.

A couple of the recommendations from the last external Clinical Coding audit in June 2005 still need to be attended to and are further re-iterated in this report as follows:

� Some urgent reappraisal of the current state of the case notes. This should include the downsizing of some volumes, efficient filing of histology/pathology reports and correct specialty divisions being maintained.

� The continuation of quarterly internal audit is recommended, as it should help to identify any potential training or information issues. Additionally every Clinical Coder should have some training at a minimum every 2 years including refresher training.

� Continue to support the excellent liaison between Clinicians and the Coding Department, especially in furthering the internal audit process. The involvement of Clinicians in the coding process should highlight to them the requirement to provide completeness and depth for assigning accurate coding within the written case notes and discharge summaries.

� Continuing current budget allocation to support the above recommendations. As Payment by Results and correct HRG allocation become increasingly important to both the Trust and their relevant PCT and Commissioning Groups, ensuring that adequate allowance for training and attendance at workshops/ conferences has been made is vital.

� Seek further clinical input as to when to code Z47.- in a primary position and include the outcome in the Coding Departments’ Policy and Procedure document.

� Review with Clinical Coding staff, the importance of assigning relevant codes for that particular episode of healthcare. The slight over coding factor revealed by this audit should then decrease. This could be further supported by providing a list of co-morbidities to be used locally and signed by the relevant Clinician to reside within the Coding Departments’ Policy and Procedure Document.

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� Maintain and update the Clinical Coding Policy and Procedures document to reflect current National Standards for ICD-10 and OPCS -4.4. Many local agreements on coding are already practiced within the Trust and all of these need to be added to this document and signed off by the relevant Clinician. This is essential to support Information Governance and Data Quality within the Trust.

� Liaise with other orthopaedic specialist Trusts to form a cohort. The review of current coding practice in spinal surgery in particular is recommended as the limitations of OPCS.4.4 for these procedures may result in differing assignment of codes and may indicate further input required for OPCS.4.5

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Appendix A

Error Key Descriptions

Unsafe to Audit Error Key

UTA UNSAFE TO AUDIT The Auditor is unable to audit the coded clinical data against the source documentation. For example: • There is no clinical information regarding the episode in the Auditor’s source

documentation to support the Auditors code assignment.

Primary Diagnosis Error Keys

Coder Error

PD3 PRIMARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL The primary diagnosis code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at third character level and incorrectly sequenced within a secondary field.

PD4 PRIMARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL The primary diagnosis code has been allocated to an incorrect fourth character. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fourth character level and incorrectly sequenced within a secondary field.

PD5 PRIMARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL The primary diagnosis code has been allocated to an incorrect fifth character. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fifth character level and incorrectly sequenced within a secondary field.

PDIS PRIMARY DIAGNOSIS INCORRECTLY SEQUENCED The primary diagnosis code recorded by the Auditor has been accurately coded but not sequenced as the primary diagnosis by the Coder.

PDO PRIMARY DIAGNOSIS OMITTED The primary diagnosis recorded by the Auditor has not been recorded by the Coder in any diagnosis field.

Non-Coder Error

PDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING Information available to the Auditors was not available at the time of coding. This is where information regarding the episode became available after the episode was coded. This error key is not to be used if the information was not accessed by the clinical Coder at the point of coding, for example, with histopathology reports. This error key would also be assigned by the Auditor when the source documentation used at the time of coding did not contain all pertinent information required for accurate and complete coding and the Coder did not have access to this information, for example, coding from proforma with no access to the casenotes.

PDD PRIMARY DIAGNOSIS DOCUMENTATION ISSUE The Auditor’s code allocated from the source documentation differs from that of the Trusts due to unclear or inconsistent information. For example: • Inconsistency between information recorded by clinical staff contained on source documentation and it is not clear which is correct • The source documentation is illegible.

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PDM PRIMARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: • by unbundling diagnoses or procedures into component parts • by adding or optimising the coded clinical data to alter the derived HRG .

PDC PRIMARY DIAGNOSIS CODED TO CLINICIAN SPECIFICATION There is a clear and documented directive from Clinicians to contravene coding to national standards or capture those instances where a Clinician has requested that coding be done in a particular way as it more accurately captures the diagnosis. For example: • by unbundling diagnoses or procedures into component parts.

PDSC PRIMARY DIAGNOSIS CODED DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses the primary diagnosis codes is technically incorrect at some level, omitted or sequenced incorrectly.

Secondary diagnosis error key descriptions

Coder Error

SD3 SECONDARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL The secondary diagnosis code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at third character level and incorrectly sequenced.

SD4 SECONDARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL The secondary diagnosis code has been allocated to an incorrect four character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fourth character level and incorrectly sequenced.

SD5 SECONDARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL The secondary diagnosis code has been allocated to an incorrect five character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fifth character level and incorrectly sequenced.

SDNR SECONDARY DIAGNOSIS NOT RELEVANT The secondary diagnosis code recorded by the Coder is not relevant to the episode of care.

SDO SECONDARY DIAGNOSIS OMITTED Diagnosis that has been recorded by the Auditor as relevant but is missing from the Organisation’s recorded episode.

SDIS SECONDARY DIAGNOSIS INCORRECT SEQUENCING The sequencing of the secondary codes contravenes national standards. This error key can only be assigned for error in the following national standards: 1. Outcome of delivery (Z37 and Z38 if not well baby) 2. Asterisk codes must be preceded by a dagger code 3. Specific coding conventions in ICD-10 i.e. use additional code 4. Extent of body surface in burns (T31, T32)

ECI EXTERNAL CAUSE CODE INCORRECT The external cause code recorded by the Organisation is incorrect at any character level.

ECO EXTERNAL CAUSE CODE OMITTED The external cause code has been omitted from the Organisation’s recorded episode.

ECNR EXTERNAL CAUSE CODE NOT RELEVANT The external cause code recorded by the Coder is not relevant to the episode of care.

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Non-Coder Error

SDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING See PDI.

SDD SECONDARY DIAGNOSIS DOCUMENTATION ISSUE The Auditor’s code allocated from the source documentation differs from that of the Trusts due to unclear or inconsistent information. For example: • Inconsistency between information recorded by clinical staff contained on source documentation and it is not clear which is correct • The source documentation is illegible.

SDM SECONDARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: • by unbundling diagnoses or procedures into component parts • by adding or optimising the coded clinical data to alter the derived HRG.

SDC SECONDARY DIAGNOSIS CODED TO CLINICIAN SPECIFICATION There is a clear and documented directive from Clinicians to contravene coding to national standards or capture those instances where a Clinician has requested that coding be done in a particular way as it more accurately captures the diagnosis. For example: • by unbundling diagnoses or procedures into component parts.

SDSC SECONDARY DIAGNOSIS CODED DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses, codes are technically incorrect at some level, omitted or sequenced incorrectly.

Primary procedure error key descriptions

Coder Error

PP3 PRIMARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL The primary procedure code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at third character level and incorrectly sequenced within a secondary field.

PP4 PRIMARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL The primary procedure code has been allocated to an incorrect four character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at fourth character level and incorrectly sequenced within a secondary field.

PPIS PRIMARY PROCEDURE INCORRECTLY SEQUENCED The primary procedure or intervention code recorded by the Auditor has been accurately coded but not sequenced as the primary procedure by the Coder.

PPO PRIMARY PROCEDURE OMITTED The primary procedure recorded by the Auditor has not been recorded by the Coder in any procedure field.

PPNR PRIMARY PROCEDURE NOT RELEVANT The primary procedure recorded by the Coder is not relevant to the episode of care.

Non-Coder Error

PPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING See PDI.

24



PPD PRIMARY PROCEDURE DOCUMENTATION ISSUE The Auditor is unable to code the clinical data from the source documentation and compare against that of the Trusts due to unclear or inconsistent information. For example: • Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct • The source documentation is illegible.

PPM PRIMARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: • by unbundling diagnoses or procedures into component parts • by adding or optimising the coded clinical data to alter the derived HRG.

PPC PRIMARY PROCEDURE CODED TO CLINICIAN SPECIFICATION There is a clear and documented directive from Clinicians to contravene coding to national standards or capture those instances where a Clinician has requested that coding be done in a particular way as it more accurately captures the intervention that occurred. For example: • by unbundling diagnoses or procedures into component parts.

PPSC PRIMARY PROCEDURE CODED DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses codes are technically incorrect at any level, omitted or sequenced incorrectly.

Secondary Procedure error key descriptions

Coder Error

SP3 SECONDARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL The secondary procedure code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at third character level and incorrectly sequenced.

SP4 SECONDARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL The secondary procedure code has been allocated to an incorrect four character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at fourth character level and incorrectly sequenced.

SPIS SECONDARY PROCEDURE INCORRECTLY SEQUENCED The Organisation has not sequenced the procedure coding according to the rules and conventions of the classification. For example: • See use as secondary code when associated with…

SPO SECONDARY PROCEDURE OMITTED Secondary procedure that has been recorded by the Auditor as relevant but is missing from the Organisation’s recorded episode.

SPNR SECONDARY PROCEDURE NOT RELEVANT The secondary procedure code recorded by the Coder is not relevant to the episode of care.

Non-Coder Error

SPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODING See PDI.

25



SPD SECONDARY PROCEDURE DOCUMENTATION ISSUE The Auditor is unable to code the clinical data from the source documentation and compare against that of the Trusts due to unclear or inconsistent information. For example: • Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct • The source documentation is illegible.

SPM SECONDARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: • by unbundling diagnoses or procedures into component parts • by adding or optimising the coded clinical data to alter the derived HRG.

SPC SECONDARY PROCEDURE CODED TO CLINICIAN SPECIFICATION There is a clear and documented directive from Clinicians to contravene coding to national standards or capture those instances where a Clinician has requested that coding be done in a particular way as it more accurately captures the intervention that occurred. For example: • by unbundling diagnoses or procedures into component parts.

SPSC SECONDARY PROCEDURE CODED DUE TO SYSTEM CONSTRAINT Due to the system that the Organisation uses codes are technically incorrect at any level, omitted or sequenced incorrectly.

26



Appendix B Overall analysis sheets Totals Number %

Total Number of episodes examined

280

UTA Unsafe to audit 0

Actual number of episodes examined

280

Number of episodes where HRG would change as a result of Auditor's coding.

1 0.36

Primary Diagnosis

Number of primary diagnoses correct

249 88.93

Non Coder Error

PDI 4 1.43

PDD

PDM

PDC

PDSC Coder Error

PD3 2 0.71

PD4 20 7.14

PD5

PDIS 3 1.07

PDO 2 0.71 Secondary Diagnosis

Number of secondary diagnoses

751

Number of secondary diagnoses correct

739 98.40

Non Coder Error

SDI

SDD

SDM

SDC

SDSC Coder Error

SD3 2 0.27

SD4 2 0.27

SD5

SDIS 3 0.40

SDO 5 0.67

SDNR 19

ECI

ECO

ECNR

27



Primary Procedures

Number of primary procedures

274

Number of primary procedures correct

270 98.54

Non Coder Error

PPI

PPD

PPM

PPC

PPSC Coder Error

PP3 1 0.36

PP4 2 0.73

PPIS 1 0.36

PPO

PPNR 1 Secondary Procedures

Number of secondary procedures

639

Number of secondary procedures correct

614 96.09

Non Coder Error

SPI 4 0.63

SPD

SPM

SPC

SPSC Coder Error

SP3 1 0.16

SP4 1 0.16

SPIS 3 0.47

SPO 16 2.50

SPNR 18

28



Totals Number %

(110) Trauma and Orthopaedics


100



100


1 1.00

Primary Diagnosis


84 84.00

Non Coder Error

PDI

PDD

PDM

PDC

PDSC Coder Error

PD3

PD4 16 16.00

PD5

PDIS

PDO Secondary Diagnosis


285


281 98.60

Non Coder Error

SDI

SDD

SDM

SDC

SDSC Coder Error

SD3 1 0.35

SD4 1 0.35

SD5

SDIS 1 0.35

SDO 1 0.35

SDNR 1

ECI

ECO

ECNR

29



Primary Procedures


97


95 97.94

Non Coder Error

PPI

PPD

PPM

PPC

PPSC Coder Error

PP3 1 1.03

PP4 1 1.03

PPIS

PPO

PPNR Secondary Procedures


189


189 100.00

Non Coder Error

SPI

SPD

SPM

SPC

SPSC Coder Error

SP3

SP4

SPIS

SPO

SPNR 6

30



Totals Number %

(171) Paediatric Surgery


100



100


0 0.00

Primary Diagnosis


89 89.00

Non Coder Error

PDI 1 1.00

PDD

PDM

PDC

PDSC Coder Error

PD3 1 1.00

PD4 4 4.00

PD5

PDIS 3 3.00

PDO 2 2.00 Secondary Diagnosis


215


211 98.14

Non Coder Error

SDI

SDD

SDM

SDC

SDSC Coder Error

SD3 1 0.47

SD4

SD5

SDIS 1 0.47

SDO 2 0.93

SDNR 6

ECI

ECO

ECNR

31



Primary Procedures


98


97 98.98

Non Coder Error

PPI

PPD

PPM

PPC

PPSC Coder Error

PP3

PP4

PPIS 1 1.02

PPO



193


186 96.37

Non Coder Error

SPI 4 2.07

SPD

SPM

SPC

SPSC Coder Error

SP3 1 0.52

SP4

SPIS 1 0.52

SPO 1 0.52

SPNR 4

32



Totals Number %

Spinal HRG Chapter R (110)


50



50


0 0.00

Primary Diagnosis


49 98.00

Non Coder Error

PDI 1 2.00

PDD

PDM

PDC

PDSC Coder Error

PD3

PD4

PD5

PDIS



191


188 98.43

Non Coder Error

SDI

SDD

SDM

SDC

SDSC Coder Error

SD3

SD4 1 0.52

SD5

SDIS

SDO 2 1.05

SDNR 12

ECI

ECO

ECNR

33



Primary Procedures


49


49 100.00

Non Coder Error

PPI

PPD

PPM

PPC

PPSC Coder Error

PP3

PP4

PPIS

PPO

PPNR 1 Secondary Procedures


196


185 94.39

Non Coder Error

SPI

SPD

SPM

SPC

SPSC Coder Error

SP3

SP4

SPIS 1 0.51

SPO 10 5.10

SPNR 8

34



Totals Number %

HRG H22 (110) Total Number of episodes examined

30



30


0 0.00

Primary Diagnosis


27 90.00

Non Coder Error

PDI 2 6.67

PDD

PDM

PDC

PDSC Coder Error

PD3 1 3.33

PD4

PD5

PDIS



60


59 98.33

Non Coder Error

SDI

SDD

SDM

SDC

SDSC Coder Error

SD3

SD4

SD5

SDIS 1 1.67

SDO

SDNR

ECI

ECO

ECNR

35



Primary Procedures


30


29 96.67

Non Coder Error

PPI

PPD

PPM

PPC

PPSC Coder Error

PP3

PP4 1 3.33

PPIS

PPO



61


54 88.52

Non Coder Error

SPI

SPD

SPM

SPC

SPSC Coder Error

SP3

SP4 1 1.64

SPIS 1 1.64

SPO 5 8.20

SPNR

36



APPENDIX C: ACTION PLAN EXTERNAL CLINICAL CODING AUDIT – ROYAL NATIONAL ORTHOPAEDIC HOSPITAL ACTION PLAN FEBRUARY 2008

Page Issue to be addressed/recommendatio

n

Priority 1= Low 2 = Med 3 = High

Responsibility

Trust to complete

Agreed

Trust to complete

Trust Comments

Trust to complete

Date

Trust to complete

Progress as at day month

2007

Trust to complete

Auditor comments

Trust to complete

19 1. Maintain and update the Clinical Coding Policy & Procedures document to reflect both current National Standards & also local coding practice that has been signed off by the clinician

3

19 2. Review the current state of the case notes and split volumes where necessary ensuring that all relevant paperwork has been filed properly into the case notes

3

37



19 3. The continuation of quarterly internal audit. Additionally every clinical coder should have some training at a minimum every 2 years including refresher training.

3

19 4. Continue to support the excellent liaison between clinicians & the coding department, especially in furthering the internal audit process, including the requirement to provide completeness & depth for assigning accurate coding within the written case notes and discharge summaries.

3

38



19 5. Seek further clinical input as to when to code Z47.- in a primary position and include the outcome in the Coding Departments’ Policy & Procedure document.

3

20 6. Liaise with other orthopaedic specialist trusts to form a cohort.

3

39



Documents

Royal National Orthopaedic Hospital NHS Trust · Royal National Orthopaedic March ... • The state of some of the case notes is of concern and raises ... This will be revised and