Abstract
Aim: Audit assessing the accuracy of clinical coding by trust guidance on revenue generation.Method: Clinical coding form containing common clinical codes placed at the front of patient notes between July 2014 and August 2014 on a respiratory ward. Medical staff, preferably registrars or consultants, recorded the primary diagnoses and comorbidities on the form. Completed forms sent to the clinical-coding department who supplied the tariff generated. Revenue generated during the test period was compared with the prior two months.Results: Comparable discharges between periods with average revenue generated a difference per patient of £339, totalling a £36,273 increase per month.Conclusion: Simple diagnoses and comorbidities coding forms completed by a senior doctor helped junior doctors improve documentation and accuracy at discharge whilst generating more revenue for the trust.
Highlights
Clinical coding is the process of recording diagnoses, treatment, investigations, and procedures that occurred during an episode of care for a patient; within primary, secondary, or tertiary care
Since April 2017, National Health Service (NHS) Digital [1] states that the standardised codes are taken from International Classification of Diseases 10th revision (ICD-10) and Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures 4th version (OPCS-4) to ensure congruity with international standards
The main source of income for healthcare trusts come from a payment structure called “Payment by Results” (PbR) which was slowly phased into the healthcare payment structure between 2003 and 2009
Summary
Clinical coding is the process of recording diagnoses, treatment, investigations, and procedures that occurred during an episode of care for a patient; within primary, secondary, or tertiary care. The fundamental information underpinning this process is the documentation by the clinicians whereby only certain information can legally be coded, for example, diagnoses preceded by “likely”, “possible”, “?” are not allowed to be coded. If this were the discharge diagnosis it could not be used to generate revenue and the trust would not receive remuneration for services provided [2,3].
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