1
SH NCP 51
Data Quality Suite of Policies
Clinical Coding Policy and Procedures
Version: 3
Summary:
This policy has been produced with the intention
of promoting good practice and consistency of
clinical coding within the Southern Health NHS
Foundation Trust. It has been designed to ensure
information produced during the coding process is
accurate, timely and adheres to local and national
policies and achieves national standards.
Keywords (minimum of 5):
(To assist policy search engine)
Clinical Coding, Clinical Coders, ICD-10, OPCS,
Validation
Target Audience:
Clinical Coding officers, Clinicians
Next Review Date:
October 2016
Approved & Ratified by:
Information
Governance Group
Date of meeting:
14/10/2015
Date issued:
October 2015
Author:
Emma Chester, Lead Clinical Coder
Version Control
Change Record
Date Author Version Page Reason for Change 10/12/12 Emma
Richardson
V1 All Reviewed to incorporate SHFT 31/10/14 Emma
Richardson
V2 1,4,7,12 Update 11/09/20
15
Emma Chester V3 4,5,6,9,1 3
Update 14/10/20
15
Emma Chester V3 5 Virtual Sign off updates.
Reviewers/contributors
Name Position Version Reviewed &
Date
IGG membership For sign off V1 23/03/2013
IGG membership For sign off V2 12/01/2014
CONTENTS
Page
1. Introduction 4
2. Statement of purpose 4
3. Clinical Coding Procedures 5
4. Validation of Clinical Coding Information 6
5. Communication in Clinical Coding 6
6. Internal Meetings and Agenda Items 6
7. Clinical Coding Team Structure and Training 7
8. Implementation and Compliance 8
9. Clinical Staff responsibilities in relation to clinical coding 8
10. Review 9
11. Distribution 9
12. Useful Contacts 9
Appendices
A1. National Clinical Coding Query Mechanism 10 A2. Top tips for coding – A guide for clinical staff 12
Clinical Coding Policy and Procedures
1. Introduction
This policy has been produced with the intention of promoting good practice and consistency of clinical coding within the Southern Health NHS Foundation Trust. It has been designed to ensure information produced during the coding process is accurate, timely and adheres to local and national policies and achieves national standards.
1.1 Clinical Coding Definition
Clinical Coding is the translation of medical terminology, as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internationally
recognised to support both statistical and clinical uses.
1.2 Clinical Coding Description
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, financial teams, information managers and data analysts along with IT Professionals.
The NHS requires input of accurate data to reflect clinical activity and trusts now have a financial incentive to ensure that coding is accurate, comprehensive and timely.
2. Statement of purpose
To provide accurate, complete, timely coded clinical information to support commissioning, local information requirements.
2.1 Adhere to national standards and classification rules and conventions as set out in the WHO ICD10 Volumes 13, National Clinical Coding Standards ICD10, OPCS -4.7, Clinical coding instruction manual OPCS 4.7 and Connecting for Health Coding Clinic.
2.2 Ensure input into Patient Administration Systems (PAS) of complete and accurately coded information, within designated time scales, to support the information
requirements and commissioning of the Southern Health NHS Foundation Trust.
2.3 Ensure all staff involved in the clinical coding process receive regular training to maintain and develop their clinical coding skills, regardless of experience and length of service.
2.4 Ensure continual improvement of the clinical coded information within the Southern Health NHS Foundation Trust through systematic audit and quality assurance procedures.
2.5 Ensure all staff are aware of the trusts security and confidentiality policies when using patient identifiable information.
3. Clinical Coding Procedures 3.1 Source Document
The source document for coding mental health patients will be the OpenRiO system. The episode should be coded using the discharge summary or letter, if created. The medical progress notes and the core assessment should also routinely be used. Should the coder need further clarification on a disorder then it is appropriate to use nursing progress notes. Every effort should be made to find as much information relating to the episode as possible
The source document for coding patients in Romsey, Fordinbridge and Lymington New Forest Hospital should primarily be Electronic Discharge Summary along with patient test results. Where the EDS have not been completed we will aim to code from patient case notes or any other source available to us at the time of coding.
The source document for Gosport, Petersfield and Fleet Hospitals should be spell summaries which will be sent to the coders from the ward clerks at the individual hospitals. Should a spell summary not reach us we aim to seek information on OpenRiO community. Should this be unsuccessful we will ensure contact with the ward clerk is achieved and further documentation made available or sent through. A record of received discharge summaries is logged.
The source document for Alton Community Hospital is case notes. A coder will attend the hospital once every 3 weeks and enter the coding on the ward computer.
3.2 Coding
The trust uses ICD-10 (International Classification of Diseases and Related Health Problems 10th revision 2010 edition) and OPCS 4.7 (Office of Population Census & Surveys version 4.7).
ICD 10 codes are also available for reference on the World Health Organisation web site:
http://apps.who.int/classifications/icd10/browse/2016/en
High cost drugs lists and Chemotherapy Regimens lists are available from
www.connectingforhealth.nhs.uk
3.3 Point of Coding
The coding process will be completed as close to patient discharge as possible. This should be primarily undertaken from the coding office based at Tatchbury Mount.
Mental Health coding will be performed through the OpenRiO system.
Any information that is not available to us through EDS should be sourced. This should be available to the coders from Lymington Hospital. Weekly visits to
Lymington Hospital should be carried out in order to code in accordance with national standards.
Gosport and Petersfield Hospitals will supply us with spell summaries for patient admissions. When these are not available contact should be made with the ward clerk and further documentation should be made available.
3.4 Time Scales
The team will aim to code all episodes within four working days of discharge. This will be monitored by the Lead Clinical Coder. Should problems arise relating to missed deadlines these will be addressed accordingly by the Lead Clinical Coder.
4. Validation of Clinical Coded Information 4.1 Internal Audits
The Lead Clinical Coder will aim to undertake an internal audit every three months using a random sample of at least 30 clinical records.
4.2 External Audits
External audits are undertaken once a year on a sample of at least 100 clinical records.
4.3 Correction of Errors
All errors identified as a result of an audit are to be corrected within one month.
4.4 Local Policies
When local policies are created the Lead Clinical Coder will inform all members of the team and ensure books are updated accordingly. Each member of staff will
responsible for creating local policies. All members of the team will sign each local policy to prove they have seen the policy.
Local policies will be divided into Mental Health and Integrated Community Services.
5. Communications in Clinical Coding
To endorse consistency and accuracy of coded information the following steps are in place:
Clinical Coding Instruction manuals ICD-10 and OPCS – 4.7, Coding Clinic and NHS Connecting for Health’s Clinical Coding Guidelines are used.
Liaison with appropriate clinician on applicable ICD-10 and OPCS 4.7 codes. Clinical Coders ensure that the advice given does not contravene the rules and conventions of the classifications or national standards. Standards agreed with clinicians are documented appropriately.
Reference to senior level coding staff to determine whether the query can be resolved internally.
Referring any query to the National Clinical Coding Query Mechanism including completion of the relevant query proforma information if appropriate. (See Appendix 1).
Distribute the resolution to the team.
Internal meetings with coding staff will be held as and when required and the agenda items will include query resolutions, internal assessments, audit feedback etc. All coding staff are required to attend the internal meetings and appropriate times will be made available when all can attend.
7. Clinical Coding Team Structure and Training 7.1 Structure
7.2 Leave
The Lead Clinical Coder will ensure that all work is covered during periods of leave (e.g. annual, sick, carer’s, special, etc.)
7.3 Training
The Lead Clinical Coder will ensure that the team attends all training as necessary. The training requirements are as follows:
Attendance of the Clinical Coding Foundation workshop within six months of appointment for all untrained coders.
Attendance on the Clinical Coding Refresher Training Course every 3 years for experienced clinical coding staff.
Attendance on regular specialist training courses wherever available.
Attendance on relevant computer training courses to keep their IT skills up-to-date.
Attendance to other relevant training courses in line with trust policies (e.g. health and safety, fire training, security and confidentiality etc.).
7.4 Induction Programmes for New Staff
An induction and training programme for all new clinical coding staff will be implemented and will include attendance on training courses, on-going in-house training and monitoring, and attendance on other relevant trust courses (e.g. health and safety, fire training, security and confidentiality etc.).
Head of
Information
Lead Clinical
Coder
1.0 wte
Clinical Coding
Officers
2 x 1.0 wte
7.5 Annual Appraisals
Individual performance appraisals and personal development plans will be undertaken yearly in line with trust policies.
8. Implementation and Compliance
8.1 Responsibilities of all staff and Non-Executive Directors
All staff (whether permanent, temporary or contracted), non-executive directors and contractors are responsible for ensuring that they are aware of the requirements incumbent upon them and for ensuring that they comply with these on a day-to-day basis.
Trust clinicians and administrative staff must forward the provider spell
summaries/discharge summary forms to the clinical coding team within two days of patient discharge.
Managers at all levels are responsible for ensuring that the staff for whom they are responsible are aware of and adhere to this policy. They should ensure that the policy and it supporting standards and guidelines are built into local processes. They are also responsible for ensuring staff are updated in regard to any changes in this policy.
8.2 Training of Non-Coding Staff
Training programmes for users of coded information and those who produce the information for coding purposes (e.g. awareness sessions, participation at induction programmes by new medical staff, etc.) will be made available on request.
9. Clinical Staff responsibilities in relation to clinical coding
There is an onus of responsibility on clinical staff at ward level to ensure that a discharge summary is completed for every patient on discharge. This includes patients who are being transferred to another facility outside of this trust and those who die.
They should attempt to ensure that the discharge summary gives clear and specific information relating to the following:
- Primary diagnosis - Secondary diagnosis
- Primary procedures (with dates) - Secondary procedures (with dates) - Co-Morbidities (Appendix 3)
- Complications of treatment
- Other factors that may have delayed the patients discharge from hospital
Clinical staff can also assist the clinical coding staff in abstraction of relevant
information and assignment of correct codes, by supplying advice and clarification on patient diagnosis and treatment when this is requested.
A top tips for coding guide has been supplied in this document. Please see appendix 2.
10. Review
This policy will be reviewed annually.
11. Distribution
This policy will be available at the Trust’s designated locations.
12. Useful Contacts
Name Job Title Telephone Number
Email Address
Emma Chester
Lead Clinical Coder
02380 874170
Julie Pointer
Clinical Coder
02380 874109
Jane Thorn Clinical Coder
02380 874216
Appendix 1: National Clinical Coding Query Mechanism
National Clinical Coding Query Mechanism
A graphic on the process to follow to answer a clinical coding query in the NHS
National Clinical Coding Query Mechanism
When a query arises follow these simple steps laid out below. The numbers refer to the boxes on the flow chart
2. First step refer to classification books (ICD-10 or OPCS-4) using the four step coding
process, the Clinical Coding Instruction Manua OPCS-4, National Clinical Coding Standards - ICD-10 4th Edition, and our technical publication the Coding Clinic
3. Research using internet sources, which may provide you with additional information. Discuss the query with your colleagues, line manager and speak to the appropriate health professional on site as they are likely to provide further information. Should your organisation have a partnership with one of the clinical coding academies you can also approach the academy for help with any clinical coding queries before taking the step to email our helpdesk. The academies have been accredited by us as reaching a level of expertise which reflects the high standards we require when providing advice on clinical coding. They work collaboratively across the regions to provide support in training, process and offer best advice to coders at the front line.
5. If further clarification is required after following all the steps above the query should be submitted to the National Clinical Classifications Helpdesk using the downloadable ICD-10 Clinical finding coding query form or the OPCS-4 Interventional clinical coding query form and providing a copy of anonymised supporting information from the patient record.
PLEASE NOTE: One query per form, different form for each classification
Fully anonymised supporting information is essential to providing a response appropriate to the particular query. Without adequate information there is a risk that an inappropriate solution code may be provided and which is consequently not strictly accurate in asnwer. Without this full information the query cannot be progressed and will delay the answer.
6. & 7. You will receive a unique log number from the helpdesk first line support and your query will then be sent on to the relevant specialist on the small core team.
8. Resolution is formulated in accordance with national clinical coding standards.
PLEASE NOTE: We are unable to answer queries relating to HRG/Payment by Results (PbR) tariff and you are recommended to forward your query to the NHS Information Centre or Department of Health PbR team
10. The draft resolution is then quality checked using our rigorous assurance process. Once this process has been satisfied the decision will be sent to you.
11 & 12. Some queries may require further specialist or clinical input or relate to policy or
principles that have implications for coding standards. In this scenario the query will be researched
further and/or consultation with other experts and then reviewed by the UK Coding Review Panel
(UKCRP). If national guidance or clarification to a standard is required this will be published in the Coding Clinic, and included in the next release of National Clinical Coding Standards reference book that are released to coincide with each classification update.
13. The UKCRP provides a collaborative focus to review and advise on coding and classifications issues affecting England, Northern Ireland, Wales and Scotland and quality assures proposed guidance. It includes representation from the clinical coding community, home countries, Department of Health, the NHS Information Centre (IC), Hospital Episode Statistics (HES) and clinical involvement
14. As well as the query being published in the Coding Clinic if there is an impact on the national standards a response to the resolution will be sent.
Appendix 2: Top tips for coding – A guide for clinical staff
Top tips for coding – A guide for clinical staff
Clinical Coding is the process whereby information written in the patient notes is translated into coded data and entered onto hospital information systems. This usually occurs after the patient has been discharged from hospital, and must be completed to strict deadlines in order for hospitals to be reimbursed for their activity.
Clinical coding staff are entirely dependent on clear, accurate information about all
diagnoses and procedures in order to produce a true picture of hospital activity. The coded data is vitally important, and is used for:
Monitoring the provision of health services across the UK
Research and the monitoring of health trends and variations
NHS financial planning and Payment by Results
Local and national clinical audit and case-mix analysis
Clinical governance
__________________________________________________________________________
There are many ways in which clinicians can assist the process of clinical coding, some of which are summarised below. Each is based on the basic principles:
1. Write clearly and legibly in the notes and on discharge documentation. Make sure the patient is identified on every sheet of paper used in the notes.
2. Always communicate any transfers of care to ward administrative staff. This includes when patients go for an investigation or procedure performed by another clinical team.
3. Clearly record the details of all of the diagnoses (including all co-morbidities) and procedures (including those done on the ward) in the notes. Write the main
diagnosis first. Best practice is to summarise all of these as the last (discharge) entry in the notes – this will make your discharge summaries easier too.
For injuries, note the cause; for overdoses, note the drug; and for infections, note the organism.
4. Include details of all diagnoses and procedures on discharge summaries and TTO’s (preliminary discharge summaries).
5. If a clear diagnosis has not been reached, make sure you detail the main symptoms in the notes or discharge summary. Any ‘query’ diagnosis e.g. likely, maybe, possibly, or diagnoses preceded by a ‘?’ cannot be coded by clinical coding staff. We are able to code a ‘probable’ diagnosis. If histology is awaited for a definitive diagnosis, note this down.
6. Avoid the use of new or ambiguous abbreviations (e.g. ‘M.S.’ could mean multiple sclerosis or mitral stenosis). Remember: clinical coding staff are not allowed to make any clinical inferences.
7. If your hospital has a standard proforma for admissions or discharge, use it! Fill in all
the details it asks for.
8. Discharge summaries must be accurate and timely. Don’t let your discharge
summaries pile up on a shelf for weeks on end, awaiting dictation – coding staff have strict deadlines to meet and delays cause huge problems. Discharge summaries
should be complete within 24 hours of discharge to allow for 48 hour post discharge coding completion.
9. You may be asked queries by the coding team if all the relevant information is not on the discharge summary, try to avoid this by completing your discharge summary as above.
Should you have any queries relating to coding please don’t hesitate to contact the coding team on:
Emma Chester [email protected]
Lead Clinical Coder 02380 874170 / 02380 874216
