Urological procedures coding: who should do it?

Abstract

This study sought to determine if consultant urologists code better than the coding department, and whether this could save the trust money. This took the form of a prospective study, where consultant urological surgeons completed electronic discharge letters for 30 elective operations during a calendar month. A clinical audit coder then reviewed the case notes independently generating another code (audit coding). These were then compared to the ‘gold-standard’ episode codes that were created by a combined team of a urologist and an experienced senior clinical coder reviewing the notes together and applying local and national standards. Errors were identified with both urologist and coding department coding. The coding department out-performed the urologists in all areas of primary and secondary diagnoses, primary and secondary procedures and resulted in a potential net loss of income of £3456 compared with a potential loss of £8468 from urologist coding. Accurate urological coding is best performed by coders not urologists, since it is complicated and requires training. Clinicians can, however, make a vital contribution by ensuring clear documentation of procedures, primary procedures and ensuring recording of all co-morbid diagnoses. Formal agreement of common codes between urologists and coders will reduce inconsistency and improve efficiency.