Improving accuracy of clinical coding in surgery: collaboration is key
| Autor: | Adam Rees, Claire Hall, James Mbuvi, Leslie Forrest, Jennifer A Smith, Cliona C. Kirwan, Jill Cunningham, Pete Charleston, Ben Hornung, Moayad al Jarabah, Janet Wilkinson, Nicholas Tarr, R.L. Teasdale, Stella R Smith, Natasha Charlwood, John Overton, Nicky Sung, Sarah E Duff, Sarah Hassan, Nick A. Heywood, Tonia Mclaughlin, Hema Sekhar, Rachel Brindle, P O Coe, Ann Jones, Michael D. Gill, James Nicholson, Natalie Allen |
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| Rok vydání: | 2016 |
| Předmět: |
medicine.medical_specialty
Emergency Medical Services Clinical coder Cohort Studies 03 medical and health sciences 0302 clinical medicine Health care Medicine Humans 030212 general & internal medicine Medical diagnosis Intersectoral Collaboration business.industry Public health Clinical Coding medicine.disease Quality Improvement Surgery Payment by Results Group code 030220 oncology & carcinogenesis Diagnosis code Medical emergency business Coding (social sciences) |
| Zdroj: | The Journal of surgical research. 204(2) |
| ISSN: | 1095-8673 |
| Popis: | Background Clinical coding data provide the basis for Hospital Episode Statistics and Healthcare Resource Group codes. High accuracy of this information is required for payment by results, allocation of health and research resources, and public health data and planning. We sought to identify the level of accuracy of clinical coding in general surgical admissions across hospitals in the Northwest of England. Method Clinical coding departments identified a total of 208 emergency general surgical patients discharged between 1st March and 15th August 2013 from seven hospital trusts (median = 20, range = 16-60). Blinded re-coding was performed by a senior clinical coder and clinician, with results compared with the original coding outcome. Recorded codes were generated from OPCS-4 & ICD-10. Results Of all cases, 194 of 208 (93.3%) had at least one coding error and 9 of 208 (4.3%) had errors in both primary diagnosis and primary procedure. Errors were found in 64 of 208 (30.8%) of primary diagnoses and 30 of 137 (21.9%) of primary procedure codes. Median tariff using original codes was £1411.50 (range, £409-9138). Re-calculation using updated clinical codes showed a median tariff of £1387.50, P = 0.997 (range, £406-10,102). The most frequent reasons for incorrect coding were “coder error” and a requirement for “clinical interpretation of notes”. Conclusions Errors in clinical coding are multifactorial and have significant impact on primary diagnosis, potentially affecting the accuracy of Hospital Episode Statistics data and in turn the allocation of health care resources and public health planning. As we move toward surgeon specific outcomes, surgeons should increase collaboration with coding departments to ensure the system is robust. |
| Databáze: | OpenAIRE |
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