Accuracy and remunerative implications of clinical coding in elective plastic surgery

Abstract

Introduction Accurate coding is essential to ensure correct remuneration for clinical procedures. However, coders are non-clinical, and use operative and discharge notes to infer what they think are appropriate codes. As plastic surgery encompasses a huge variety of procedures, the codes used may not reflect the procedures performed. Methods Electronic records from July/August 2019 were consulted to identify commonly performed procedures on elective lists that were then reviewed retrospectively by a coding auditor and a clinician. Procedures were chosen to reflect a range of plastic surgery, including hand surgery, breast surgery and general plastic surgery. The changes to the clinical codes (procedural and diagnostic) and Healthcare Resource Group tariff implications were analysed. The audit loop was completed in July 2020 after the introduction of clinical coding improvement strategies. Results A total of 65 relevant cases were included. Changes were made in 31 cases (24 changes to OPCS-4 codes and 7 changes to ICD-10 codes). Significant remunerative implications for the department were noted (£209 per patient on average). Conclusions This study has demonstrated a clear need for collaboration between clinicians and coders. Increased surgeon awareness of clinical coding and clear documentation are essential. We have presented strategies to improve coding as part of a continued quality improvement.