ࡱ> HKABCDEFGy bjbj 7{{     4448l( t4Z(("(((**4*`ZbZbZbZbZbZbZ$\_Z *****Z  ((HZ666*r ( (`Z6*`Z666QS(WKJxb,QLZZ0ZR_`<2_`8SS:_` S\**6*****ZZ4***Z****_`********* :  Heart of England NHS Foundation Trust Clinical Coding Information Governance Audit Report (Audit carried out, June 2015 December 2015) Auditor: Emily Johnson Accredited Clinical Coder (ACC) Approved Clinical Coding Auditor Apprentice Clinical Coding Trainer (TAP cert.) Heart of England NHS Foundation Trust Bordesley Green East Birmingham B9 5SS  Contents Executive Summary Page 3 -General Finding Page 4 -Recommendations Page 5 Full Report Page 6 Introduction Page 6 Aims Page 6 Objectives Page 6 Background Page 6 Methodology Page 8 General Findings Page 9 Primary diagnosis Page 10 Secondary diagnosis Page 12 Primary procedures Page 15 Secondary procedures Page 17 Conclusion Page 19 Recommendations Page 19 Appendix A Clinical Coding Audit Worksheet Page 20 Appendix B Error Key Descriptions Page 21 Appendix C Analysis of Errors Page 28 Appendix D List of Published References Page 30 Executive Summary Introduction Clinical coding is an important process to achieve payment by results as it links the activity of the Trust to the payment. Regular audits should be undertaken to ensure clinical data is accurate and National Clinical Coding Standards are being adhered to. Coded clinical data supports operational and clinical needs of commissioning. This audit was carried out in line with Information Governance (IG) Requirement 505. Emily Johnson, accredited clinical coder, approved auditor and apprentice trainer undertook the audit from June 2015 to December 2015. Emily has been coding for ten years and became Clinical Coding Auditor in January 2013 for Heart of England NHS Foundation Trust. Aims This audit will: evaluate the quality of coded clinical data and source documentation identify areas where best practice is or is not being achieved. Objectives The audit will identify any coding errors and check the accuracy of the coded clinical data. It will identify any areas of concern and make recommendations as appropriate. Background The Heart of England NHS Foundation Trusts Clinical Coding team consists of three separate hospital sites. There is a Head of Coding, a Clinical Coding Auditor, trainee Auditor, two Site Supervisors and four Senior Coders all of which have gained their National Clinical Coding qualification (ACC). There is a total of 30.57 whole time equivalent (WTE) Clinical Coders of which ten are accredited (ACC) (excluding the Head of Coding, Auditor, trainee Auditor and Supervisors). There are two NHS Classification Service (NCS) approved experienced trainers, one NCS approved apprentice trainer and four NCS approved auditors within the team. There is currently one vacancy within this department and three trainees. In 2015/16, the coding team completed 300,400 finished consultant episodes (FCEs) from source documents. There is a rigorous audit programme for individual coders. Speciality specific audits are completed on an ad-hoc basis in 2015/16. Clinician validation is limited to certain specialties. No speciality training has been performed as the Trust has revoked the membership with the local academy and has no access to speciality training materials. General findings - summary The auditor examined 1000 episodes. Table 1 shows that Heart of England NHS Foundation Trust has achieved the requirements of Information Governance 505 level 2 (see appendix C for a full breakdown of results) Table 1: Coding Accuracy at Heart of England NHS Foundation Trust 15/16 Number of episodes audited% CorrectPrimary DiagnosisSecondary DiagnosisPrimary ProcedureSecondary Procedure100090.9%91.9%92.7%91.3% Table 2 shows the Information Governance audit results for clinical coding at Heart of England NHS Foundation Trust since 2008/09. There has been year on year improvement in performance, with the Trust achieving IG Level 2 last year as well. Table 2: Coding Accuracy at Heart of England NHS Foundation Trust 08/09 15/16 Year of Information Governance audit Primary DiagnosisSecondary DiagnosisPrimary ProcedureSecondary Procedure2008-0971%49%75%67%2009-1067.5%61.2%74.4%84.9%2010-1172.9%68.6%84.6%80.4%2012-1391%90.2%90.5%94.8%2013-1490.4%92.4%93.0%86.6%2014-15 91.1%91.5%91.8%90.5%2015-1690.9%91.9%92.7%91.3%*the trust did not have an audit in 2011/12 Most case notes were in good order. In some specialties discharge summaries and Korner Medical Record (KMRs) are used as the main source documentation. It was found that limited information is provided on these documents leading to 23 errors when compared to the full case notes. Conclusion 1. Coding standards are not always adhered to; in particular the four step coding process, also essential co morbidities and acute conditions are not being recorded. 2. In some areas only a carbon copy of the Korner Medical Records (KMR) or discharge summary is used as a source document. Information on these proforma is insufficient which lead to 23 errors. 3. Mandatory coding courses are being undertaken in house. Previous recommendation of implementing speciality training plan has not been undertaken due to various reasons. The Trust is no longer a member of the local coding academy and no longer has access to the speciality training materials. The Trust also has had issues with coding resource over the past year leaving no time to undertake speciality workshops. This has potential impact on coding accuracy and its cohort of data users. Recommendations 1. Feedback to individual coders within the next 3 months to ensure that all coding standards are being adhered to. 2. Improve the quality of information received by the Clinical Coding department to reduce non coder errors by the next Information Governance audit in 2016/17. 3. Perform a training needs analysis to identify if any speciality training needs to be undertaken and also focus on what specialities need to be focused on by April 2016. Full Report Introduction Clinical coding is an important process to achieve payment by results as it links the activity of the Trust to the payment. Data derived from Clinical Coding supports operational and clinical needs of both the Trust and commissioners. Coded clinical data must be accurately recorded and regular audits should be one of the steps to check this. A clinical coding audit is an official detailed examination of the coded clinical data captured. This audit has been requested to ensure confidence in the information produced and to check that the underlying data is of quality and fit for purpose. This audit was requested by the Head of Coding in line with Information Governance (IG) Requirement 505. Aims This audit is required to ensure confidence in the information produced and evaluate the quality of coded clinical data. It is to identify areas where best practice is or is not being achieved and provide a baseline benchmark for continuous improvement in clinical coding. Objectives The audit will identify any coding errors and compare the information provided to the Clinical Coders at the time of coding with the information documented in the case notes. It will also check the accuracy of the coded clinical data and whether National Standards are being adhered to. The audit will identify any areas or training issues of concern and make recommendations where appropriate. It will also review the quality of source documentation produced at the Trust. Background The Heart of England NHS Foundation Trusts Clinical Coding team consists of three separate hospital sites. There is a Head of Coding, a Clinical Coding Auditor, trainee Auditor and two Site Supervisors all of which have gained their National Clinical Coding qualification (ACC). At the time of writing this report there is a total 30.57 of whole time equivalent (WTE) Clinical Coders, of which ten are accredited (ACC) (excluding Head of Coding, Auditor, trainee Auditor and Supervisors). There are currently four Senior Clinical Coders, three trainee coders and two WTE vacancies. Over the past year the Clinical Coding Department has suffered with coding resources and has lost a number of experienced staff. There are two NHS Classification Service (NCS) approved experienced trainers and one NCS approved apprentice trainer all of which have other duties besides training. The Trust is holding a standards course for the three trainee coders starting in April 2016. The rest of the team have attended the mandatory national standards course or the clinical coding refresher course within the last three years. The Trust has opted out of membership with the local academy due to lack of spaces and courses held the previous year. The Trust do not currently hold speciality workshops. There are four trained NCS approved auditors, all of which have other duties besides auditing, and one trainee auditor onsite. Regular individual coder quality assurance audits, individual coder real time audits and mortality audits are carried out. There are some formal validations in cardiology, palliative care, pressure ulcers, acute myocardial infarction in deceased patients, renal, bone marrow transplants, stroke, neck of femur fractures and infectious diseases. DQA software is also being used to provide extra rigorous validations. Ad hoc validations take place through emails from the coders to the clinicians when a specific query arises in all specialities. The Clinical Coding team also have an internal coding review panel which is a group set up to answer the more difficult coding queries where no standard exists. The coding extraction is ward based, the coding process is centralised in the office. The clinical coders have no other duties aside from accurate extraction of complex clinical details relating to diagnosis and operational interventions for each finished consultant episode (FCE) from various source documents. The source documents used at the Trust are proformas, Korner Medical Records (KMR), case notes and discharge summaries as well as partial electronic patient records for radiology, histology and some surgical interventions. The Clinical Coding department then undertakes coding of this clinical information using ICD 10 and OPCS 4.7 classifications. They ensure National Standards are adhered to and are in accordance to the Trusts Policy and Procedure document. The Trusts Clinical Coding Policy and Procedure document is updated to reflect national and local procedural changes with dates when changes are implemented from. Senior Clinical Coders have other duties which include being a cluster lead to a group of coders, answering coding queries, mentoring trainees, the coding role and supporting the Clinical Coding Supervisor with the day to day running of the department. All coders will have an individual audit on their work every year as a minimum. If the coder is not reaching the recommended accuracy of Information Governance level two then extra support is implemented and the coder is placed on performance management to ensure the coder receives the necessary support that is needed. An audit is undertaken after six months to check progress. Trainees are not formally audited until the clinical coding standards course has been completed. After every internal audit all coders are made aware of their individual errors and the guidance in order to correct themselves. This is done face to face with the auditor and the coder with source documentation where possible. Spot checks are also carried out to provide extra support within the coding process, extraction is not included. If any common themes through audits have been identified then these will feature in the Coding Matters monthly newsletter which is emailed out to all members of the Clinical Coding department every month, this newsletter also includes any queries resolved from the internal review panel. The Trust has seen an increase in the total FCEs and the average of FCEs per coder has also significantly increased over the last three years as shown in table 1. Table 1: Trusts FCEs per year Financial yearWTE coderTotal FCE countAverage per coder2013/1431.16262,5008,4242014/1527.8265,3659,2142015/1630.57300,4009,826 Methodology This audit has been carried out to the national methodology contained in the NHS HSCIS Audit Methodology Version 9.0. Emily Johnson Accredited Clinical Coder, Approved Clinical Coding Auditor and Apprentice Clinical Coding Trainer who has been coding for ten years, carried out the audit. Emily was appointed Clinical Coding Auditor in January 2013. The individual audits were carried out between June 2015 and December 2015. The audits were carried out using 3M Medicode audit software. For Information Governance purposes NHS trusts are required to carry out an internal clinical coding audit programme of a minimum of 200 records either as a one off audit or as part of a process of a continuous clinical coding audit. A total of 1000 episodes were audited. These audits were carried out on 20 individual coders as part of the quality assurance process to ensure accuracy is being maintained. The auditor extracted all relevant diagnostic and procedural information from the clinical case notes and assigned appropriate codes. All relevant rules, conventions and standards pertaining to the ICD-10 and OPCS 4.7 classifications, national clinical coding standards book ICD-10 4th edition and OPCS 4.7 clinical coding standards book and changes to standards as published in the Coding Clinic insert of the Data Quality Review and Dataset Change Notices were applied. Comparisons were then made between the information extracted from the source document by the auditor and the information provided to SUS to evaluate the level of coding accuracy. Codes were considered accurate if they described the actual condition of the patient (and any procedures performed) as completely as possible within the constraints of the classifications used and as complete as necessary for the intended use of the data. The three dimensions of coding accuracy are: Individual Codes are they an accurate reflection of the clinical statement? Totality of Codes do they represent all the relevant clinical details? Sequencing of codes are the codes in the correct sequence as defined by the rules and conventions of the classifications and the mandated definition of a primary diagnosis? Coding errors were then evaluated as follows: Documentation issues Incorrect main diagnosis / procedure selected Incorrect three character category Incorrect four character category Omission of diagnosis/procedure codes Incorrect sequencing of codes Diagnostic information is required for the recording of both primary and secondary diagnoses for each episode of patient care. On discharge the patient should be assigned a primary diagnosis even if a definitive diagnosis is not available. In addition to the primary diagnosis, all relevant secondary diagnoses should be recorded within the current episode of care on the source documentation. Information regarding surgical procedures undertaken is required for every episode of patient care, and should be documented in the clinical record by the clinical staff responsible for the patient. It is generally considered that the procedure of most relevance should be selected as the primary procedure i.e. the main surgical operations in terms of complexity and use of resources. Secondary procedures are considered to include supplementary procedures such as diagnostic procedures or which are less complex that the main procedure. Codes in chapter Z subsidiary classification of sites of operation are included in audit figures where they add additional information as per OPCS 4.7 standards book reference CSZ1. General findings Most case notes were in good order, which aided the navigation of the notes for the purpose of clinical coding. However the process for receiving information is not standardised across the trust and some specialities rely on discharge summaries and proformas or KMRs only. Information on the discharge summaries and KMRs are limited. The level of achievement required for Information Governance level two is 90% coding accuracy for primary diagnoses and primary procedures. It is also required that secondary diagnoses and secondary procedures be coded to 80% accuracy. Table 2 shows that Heart of England NHS Foundation Trust has achieved the requirements of Information Governance 505 level two (see appendix C for a breakdown of all percentages) Number of episodes audited% CorrectPrimary DiagnosisSecondary DiagnosisPrimary ProcedureSecondary Procedure100090.9%91.9%92.7%91.3%Table 2: Coding Accuracy at Heart of England NHS Foundation Trust 2014/15 Table 3 shows the Information Governance audit results for clinical coding at Heart of England NHS Foundation Trust since 2008/09. Trust is achieving IG level two this year and generally stabilising at IG level two in recent years. Table 3: Coding Accuracy at Heart of England NHS Foundation Trust 08/09 15/16 Financial year of Information Governance audit Primary DiagnosisSecondary DiagnosisPrimary ProcedureSecondary Procedure2008-0971%49%75%67%2009-1067.5%61.2%74.4%84.9%2010-1172.9%68.6%84.6%80.4%2012-1391%90.2%90.5%94.8%2013-1490.4%92.4%93.0%86.6%2014-1591.1%91.5%91.8%90.5%2015-1690.9%91.9%92.7%91.3%*the trust did not have an audit in 2011/12 Primary diagnoses Primary diagnosis is achieving the recommended target from Information Governance which was 90% of primary diagnosis codes should be correctly coded, Heart of England NHS Foundation Trust obtained 90.9% correct. Of the 1000 primary diagnoses there were 94 primary diagnoses which were incorrect; ten were incorrect due to non coder error; 84 were incorrect due to coder error. Below is the breakdown of incorrect diagnoses (see appendix C for all percentages and see appendix B for the error key assignment) There were ten instances where the primary diagnoses were incorrect due to information not being available to the coder at the time of coding. Example: The coder had access to the patients casenotes however the purple postnatal book is not filed within the patients notes until after 42 days which stated the baby had jaundice The case notes did not state jaundice. The coder did not have access to the purple postnatal book which lead to the incorrect assignment of codes. Trusts codingAuditors codingError KeyZ38.0 Singleton, born in hospitalP59.9 Neonatal jaundice, unspecified Z38.0 Singleton, born in hospital PDI There were 25 cases where the primary diagnosis was incorrect at third character level. Example: Patient diagnosed with chest infection, X-ray showed consolidation of left lower lobe. Trusts codingAuditors codingError keyJ22.X Unspecified acute lower respiratory infectionJ18.1 Lobar pneumonia unspecified PD3Rationale: Reference DCS.X.5: COAD/COPD, chest infection and asthma with associated condition states chest infection with lower lobe consolidation should be coded to J18.1 There were 33 episodes where the primary diagnosis was incorrect at fourth character level. Example: Patient diagnosed with abscess of stomach. Trusts codingAuditors codingError keyK31.9 Disease of stomach and duodenum, unspecifiedK31.8 Other specified diseases of stomach and duodenumPD4Rationale: Reference 2.4.5 of ICD-10 volume two states the fourth character .8 is generally used for other conditions belonging to the three-character category, and .9 is mostly used to convey the same meaning as the three-character category title, without adding any additional information. As the stomach abscess is an other disease of the stomach the .8 should be used in preference to the .9. In twelve cases the primary diagnosis code was incorrectly sequenced. Example: Patient was admitted to hospital for treatment of UTI; whilst in hospital the patient suffered a seizure in which in the second finished consultant episode (FCE) underwent CT scan, lumbar puncture and multiple other observations to find the cause of the seizure. In the second FCE it was clearly documented that the seizure was now the main condition being investigated. Trusts coding (first FCE)Auditors codingError key N39.0 Urinary tract infection, site not specified R56.8 Other and unspecified convulsionsR56.8 Other and unspecified convulsions N39.0 Urinary tract infection, site not specifiedPDISRationale: Reference DGCS.1: Primary diagnosis definition states the first diagnosis of the coded clinical record will contain the main condition treated or investigated during the relevant episode of healthcare. From this audit eleven primary diagnoses were not coded at all. Example: The patient was admitted to hospital with arm cellulitis. In the second FCE the patient developed a chest infection in which was subsequently treated however no evidence documented of chest infection within the first FCE. Trusts codingAuditors coding Error keyJ22.X Unspecified acute lower respiratory infectionL03.1 Cellulitis of other parts of limb PDO Rationale: Reference DGCS.1: Primary diagnosis definition states the first diagnosis of the coded clinical record will contain the main condition treated or investigated during the relevant episode of healthcare. Secondary diagnoses Secondary diagnoses hit the recommended target from Information Governance which was 80% of data should be correctly coded, Heart of England NHS Foundation Trust obtained 91.9% correct, below is the break down of the incorrect secondary procedures (see appendix C for all percentages and appendix B for error key assignment). Of the 5,436 codes; 428 secondary diagnosis codes were incorrect due to coder error; fifteen secondary diagnosis codes were incorrect due to non coder error. There were eleven code coded in secondary diagnoses were found to be incorrect due information not being available at the time of coding. Example: The coder had access to the patients casenotes however the purple postnatal book is not filed within the patients notes until after 42 days which stated the baby had jaundice and sticky eye which was swabbed. The case notes did not state this information and the patients primary diagnosis was an facial injury due to forceps. The coder did not have access to the purple postnatal book which lead to the incorrect assignment of codes. Trusts codingAuditors coding Error keyP15.4 Birth injury to face Z38.0 Singleton born in hospital P15.4 Birth injury to face Z38.0 Singleton born in hospital P59.9 Neonatal jaundice, unspecified P39.1 Neonatal conjunctivitis and dacryocystitis H10.0 Mucopurlent conjunctivitis SDI SDI SDI In four cases secondary diagnoses were incorrect due to inconsistent documentation recorded in the case notes. Example: Patient was described as type one diabetes and type two diabetes multiple times throughout the case notes. This is very confusing for the coder with conflicting information within the notes. Trusts codingAuditors codingError keyE10.9 Insulin-dependent diabetes mellitus, without complications E11.9 Non-insulin-dependant diabetes mellitus, without complicationsSDD There were 60 instances where the secondary diagnoses were incorrect at third-character level. Example: Patient described as sustaining a bruise to the thigh during the hospital stay. Trusts codingAuditors codingError keyT13.0 Superficial injury of lower limb, level unspecified S70.1 Contusion of thighSD3Rationale: Four step coding process, page 10 of ICD-10 standard book, leads the coder to the correct code when process followed correctly. Index under bruise, see also contusion. From this audit 51 secondary diagnoses were coded inaccurately at fourth-character level. Example: Patient was admitted with multiple symptoms, one of which was central chest pain. Trusts codingAuditors codingError keyR07.4 Chest pain unspecifiedR07.2 Precordial painSD4Rationale: Reference DCS.XVIII.1: Central and musculoskeletal chest pain (R07.2 and R07.3) states central chest pain must be classified to code R07.2. There were eight secondary diagnoses coded incorrectly recorded at fifth-character level. Example: Patient was described as having pain in the shoulder and elbow. Trusts codingAuditors codingError keyM25.52 Pain in joint, elbow M25.51 Pain in joint, shoulderM25.50 Pain in joint, multiple SD5 SDNRRationale: Reference DChS.XIII.1 states fifth character of 0 indicates involvement of multiple sites. It should be assigned when the condition classified at the fourth character code affects more than one site. There are 261 secondary diagnosis codes was omitted. Example: Patient admitted and treated for an epileptic fit, patient has a co-morbidity of hypertension documented Trusts codingAuditors codingError keyG40.9 Epilepsy, unspecifiedG40.9 Epilepsy, unspecified I10.X essential(primary) hypertension  SDORationale: Reference 88 of the Coding Clinic states hypertension is an essential co-morbidity and must be coded when documented. There were nine occasions where the secondary diagnosis was incorrectly sequenced. Example: The patient had ischaemic heart disease and hypertension documented as co-morbidities. Trusts coding (second FCE)Auditors codingError keyI10.X Essential (primary) hypertension I25.9 Chronic ischaemic heart disease, unspecifiedI25.9 Chronic ischaemic heart disease, unspecified I10.X Essential (primary) hypertension SDIS Rationale: Guidance under DCS.IX.1 states when assigning hypertension as a secondary code with an ischaemic heart condition classifiable to categories I20-I25 Ischaemic heart diseases or cerebrovascular disease classifiable to categories I60-I69 Cerebrovascular disease as instructed in the category Use note, the hypertension can be sequenced in any secondary position. There were 22 occasions where the external cause code was omitted. Example: Patient being treated for lobar pneumonia. Clinician had stated that this was hospital acquired. Trusts coding (second FCE)Auditors codingError keyJ18.1- Lobar pneumonia, unspecifiedJ18.1- Lobar pneumonia, unspecified Y95.X Nosocomial condition ECORationale: Reference DCS.XX.10: Hospital acquired conditions (Y95.X) states when the responsible consultant has documented in the medical record that a condition is hospital acquired code Y95.x must be assigned after the condition code. There were three instances where the external cause code was incorrect. Example: Patient fell at home and sustained a pertronchanteric fracture. Trusts codingAuditors codingError keyS72.10 pertronchanteric fracture, closed W19.9 Unspecified fall, unspecified place S72.10 pertronchanteric fracture, closed W19.0 Unspecified fall, home  ECIRationale: Four step coding process, page 10 of the ICD-10 standards book states the coder must verify the code in the tabular, the fourth character .0 would have been coded if this process was fully applied. Primary procedures The primary procedure accuracy achieved the recommended target from Information Governance which was 90% of data should be correctly coded. Heart of England NHS Foundation Trust obtained 92.7% accuracy; below is the break down of the incorrect secondary procedures (see appendix C for all percentages and appendix B for error key assignment). Of the 436 primary procedure codes; 31 were incorrect due to coder error and one code was incorrect due to non coder error. On one occasion the primary procedure was incorrectly coded due to the information not being available at the time of coding. Example: Patient admitted to the ward and received anti D. Coder only had access to discharge summary which did not state the anti D was given. Trusts codingAuditors codingError keyNothing codedX30.1 Injection of RH immune globulinPPIRationale: Anti-D must always be coded as per PCSR8 There were seven primary procedures wrongly coded due to being incorrect at third character level . Example: Patient sustained fracture dislocation of carpometacarpal joint of finger. Patient underwent closed reduction and internal fixation. Trusts codingAuditors codingError keyW24.2 Closed reduction of fracture of long bone and rigid internal fixation NECW66.4 Primary closed reduction of fracture dislocation of joint and internal fixationPP3Rationale: Fracture dislocations have their own separate categories, if the full four step coding process was applied it would lead the coder to the correct code. Four primary procedures were incorrect at fourth character level. Example: Patient attended hospital for extraction of ureteric stones using an ureteroscope. Trusts codingAuditors codingError keyM27.2 Ureteroscopic fragmentation of calculus of ureter NEC M27.3 Ureteroscopic extraction of calculus of ureterPP4Rationale: Coder did not follow the four step coding process, detailed on page 10 of the OPCS 4.7 standards book. There were four instances where the primary procedure was incorrectly sequenced. Example: Patient electively admitted to hospital for a debridement using arthroscopic microfracture technique. Trusts codingAuditors codingError keyW80.2 Open debridement of joint NEC Y76.7 Arthroscopic approach to joint W84.5 Endoscopic drilling of epiphysis for repair of articular cartilage.W84.5 Endoscopic drilling of epiphysis for repair of articular cartilage. PPIS SPNR SPNR Rationale: Debridement was performed using a microfracture technique, this was not two separate debridements. W80.2 Open debridement of joint NEC code has the abbreviation of NEC and therefore this prompts the coder to look elsewhere as per PConvention 3 There were fourteen cases where the coding of primary procedures were omitted. Example: Aspiration of joint was performed to diagnose pseudogout with acute oligoarthritis. Trusts codingAuditors codingError keyNothing codedW90.1 Aspiration of joint PDORationale: Reference PRule 1 of the OPCS 4.7 standards book states procedures should always be recorded when documented. Secondary procedures The secondary procedure coding accuracy achieves the recommended target from Information Governance which was 80% of data should be correctly coded. Heart of England NHS Foundation Trust obtained 91.3%; below is the break down of the incorrect secondary procedures (see appendix C for all percentages and appendix B for error keys). Of the 958 secondary procedural codes, 82 were incorrect due to coder error and one was due to non coder error. On one occasion the secondary procedure was incorrectly coded due to the information not being available at the time of coding. Example: Patient underwent a bedside echocardiogram however this information was not available to the coder at the time of coding. Trusts codingAuditors codingError keyL91.2 Insertion of central venous catheter NEC Y53.2 Approach of organ under ultrasonic control Z94.2 Right sided operation L91.2 Insertion of central venous catheter NEC Y53.2 Approach of organ under ultrasonic control Z94.2 Right sided operation U20.1 Transthoracic echocardiogram SDIRationale: Anti-D must always be coded as per PCSR8 From this audit four errors occurred at third character level for secondary procedures. Example: Patient underwent aspiration of knee joint. Trusts codingAuditors codingError keyW90.1 Aspiration of joint O13.2 Knee NECW90.1 Aspiration of joint Z84.6 Knee joint  SP3Rationale: The abbreviation NEC acts as a prompt to direct the coder to look elsewhere as per PConvention 3. Also notes at category O13 states that codes from this category should not be used when more specific site codes may be identified, four step coding process, page 10 of OPCS 4.7 standards book. There was one secondary procedural code incorrect at fourth character. Example: Patient underwent CT of head, neck and chest. Trusts codingAuditors codingError keyU21.2 Computed Tomography NEC Y98.1 Radiology of one body area (or <20 minutes)U21.2 Computed Tomography NEC Y98.3 Radiology of three body areas (or 20-40 minutes) SP4Rationale: Coder had used to default code of one body area however PCSU2 states head, neck and chest are separate body areas and therefore counted as three body areas. From this audit one secondary procedural code was incorrectly sequenced. Example: Patient underwent balloon dilation of the oesophagus using OGD and under X-ray control. Trusts codingAuditors codingError keyG44.3 Fibreoptic dilation of upper gastrointestinal tract NEC Y53.1 Approach to organ under radiological organ Y40.3 Balloon dilation of organ NOCG44.3 Fibreoptic dilation of upper gastrointestinal tract NEC Y40.3 Balloon dilation of organ NOC Y53.1 Approach to organ under radiological organ  SPISRationale: Y53.- must be sequenced after intervention and before the site codes as per PCSY7. Y40.3 must be sequenced before Y53.-, look at examples PCSG1. There were 76 secondary procedures omitted and not coded. Example: Patient underwent aspiration of right knee joint for knee joint effusion, whilst an inpatient the patient went into retention and a catheter was inserted. Trusts codingAuditors codingError keyW90.1 Aspiration of joint Z84.6 Knee joint Z94.2 Right sided operation W90.1 Aspiration of joint Z84.6 Knee joint Z94.2 Right sided operation M47.9 Urinary catheterisation  SPORationale: Reference PCSM6 states urinary catheters must be coded when they are not routine part of care. This patient went into retention and therefore this was not routine part of care and the urinary catheter must be assigned. Conclusion 1. Heart of England Foundation Trust is achieving the recommended Information Governance level two requirements. However, some coding standards are not being adhered to, evidenced by 198 of third, fourth and fifth character errors within this audit. Improvements can predominantly made by adhering to the rules outlined on pages: The full four step coding process; page 10 of the ICD-10 reference manual; and pages 10 of the OPCS 4.7 standard book Another national standard not being followed is the coding of secondary diagnosis as per coding clinic reference 88. This is evidenced by the 261 secondary diagnosis omitted which shows essential co-morbidities and acute conditions are not all being fully captured. The impact of these errors result in inconsistencies in data and potentially loss of income for the Trust. 2. The process for receiving information is not standardised. In some areas only a carbon copy of the Korner Medical Records (KMR) or discharge summary is used as the source document. The information on the KMR or discharge summary was sometimes insufficient and more information was found in the case notes. If the case notes were used for coding of these episodes then 23 errors could have been avoided. 3. Mandatory coding courses are being undertaken in house. Previous recommendation to implement a formal speciality training plan was not achieved last year due to various reasons. The Trust is no longer a member of the local coding academy and does not have access to speciality course materials. Currently no speciality training is being undertaken due to this reason as well as issues with staff resources. This has potential impact on coding accuracy and its cohort of data users. Recommendations 1. Feedback to individual coders within the next 3 months to ensure all coding standards are being adhered to including general highlights in the monthly coding newsletter. 2. Improve the quality of information received by the Clinical Coding department to reduce non coder errors by the next Information Governance audit in 2016/17. 3. Perform a training needs analysis to identify if any speciality training needs to be undertaken and also focus on what specialities need to be focused on by April 2016. Appendix A - Clinical Coding Audit Worksheet Organisation/Trust:Heart of England NHS Foundation TrustAudit Date: Episode Details Record ID:Specialty:MoA:Episode StartEpisode EndLoS:Adm. StartAdm. EndAge Source Documentation Clinical recordDischarge summaryProformaDischarge letterOther (please specify) Coding Analysis - Diagnoses Organisation CodingAuditor CodingError KeyDiagnosisCodeCodeDiagnosis1.2.3.4.5.6.7.8.9.10. Coding Analysis Procedures/Interventions Organisation CodingAuditor CodingError KeyProcedureCodeCodeProcedure1.2.3.4.5.6.7.8.9.10. HRG Analysis Organisation spell HRGOrganisation episode HRGAuditor HRG Appendix B - Error Key Descriptions Unsafe to Audit Error Key UTAUNSAFE TO AUDITThe auditor is unable to audit the coded clinical data against the source documentation. For example: There is no clinical information regarding the episode in the auditors source documentation to support the auditors code assignment. Primary Diagnosis Error Keys Coder Error PD3PRIMARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVELThe primary diagnosis code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at third character level and incorrectly sequenced within a secondary field.PD4PRIMARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVELThe primary diagnosis code has been allocated to an incorrect fourth character. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fourth character level and incorrectly sequenced within a secondary field.PD5PRIMARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVELThe primary diagnosis code has been allocated to an incorrect fifth character. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fifth character level and incorrectly sequenced within a secondary field.PDISPRIMARY DIAGNOSIS INCORRECTLY SEQUENCEDThe primary diagnosis code recorded by the auditor has been accurately coded but not sequenced as the primary diagnosis by the coder.PDOPRIMARY DIAGNOSIS OMITTEDThe primary diagnosis recorded by the auditor has not been recorded by the coder in any diagnosis field. Non-Coder Error PDIINFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODINGInformation available to the auditors was not available at the time of coding. This is where information regarding the episode became available after the episode was coded. This error key is not to be used if the information was not accessed by the clinical coder at the point of coding, for example, with histopathology reports. This error key would also be assigned by the auditor when the source documentation used at the time of coding did not contain all pertinent information required for accurate and complete coding and the coder did not have access to this information, for example, coding from proforma with no access to the case notes.PDDPRIMARY DIAGNOSIS DOCUMENTATION ISSUEThe auditors code allocated from the source documentation differs from that of the Trusts due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on source documentation and it is not clear which is correct The source documentation is illegible.PDMPRIMARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG.PDCPRIMARY DIAGNOSIS CODED TO CLINICIAN SPECIFICATIONThere is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures the diagnosis. For example: by unbundling diagnoses or procedures into component parts.PDSCPRIMARY DIAGNOSIS CODED DUE TO SYSTEM CONSTRAINTDue to the system that the Organisation uses the primary diagnosis codes is technically incorrect at some level, omitted or sequenced incorrectly. Secondary diagnosis error key descriptions Coder Error SD3SECONDARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVELThe secondary diagnosis code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at third character level and incorrectly sequenced. SD4SECONDARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVELThe secondary diagnosis code has been allocated to an incorrect four character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fourth character level and incorrectly sequenced.SD5SECONDARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVELThe secondary diagnosis code has been allocated to an incorrect five character code. Or, where it is clear the code allocated to classify the disease or health related problem is incorrect at fifth character level and incorrectly sequenced.SDNRSECONDARY DIAGNOSIS NOT RELEVANTThe secondary diagnosis code recorded by the coder is not relevant to the episode of care.SDOSECONDARY DIAGNOSIS OMITTEDDiagnosis that has been recorded by the auditor as relevant but is missing from the Organisations recorded episode.SDISSECONDARY DIAGNOSIS INCORRECT SEQUENCINGThe sequencing of the secondary codes contravenes national standards. This error key can only be assigned for error in the following national standards: Outcome of delivery (Z37 and Z38 if not well baby) Asterisk codes must be preceded by a dagger code Specific coding conventions in ICD-10 i.e. use additional code Extent of body surface in burns (T31, T32).ECIEXTERNAL CAUSE CODE INCORRECTThe external cause code recorded by the Organisation is incorrect at any character level.ECOEXTERNAL CAUSE CODE OMITTEDThe external cause code has been omitted from the Organisations recorded episode.ECNREXTERNAL CAUSE CODE NOT RELEVANTThe external cause code recorded by the coder is not relevant to the episode of care. Non-Coder Error SDIINFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODINGSee PDI.SDDSECONDARY DIAGNOSIS DOCUMENTATION ISSUEThe auditors code allocated from the source documentation differs from that of the Trusts due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on source documentation and it is not clear which is correct The source documentation is illegible.SDMSECONDARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG.SDCSECONDARY DIAGNOSIS CODED TO CLINICIAN SPECIFICATIONThere is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures the diagnosis. For example: by unbundling diagnoses or procedures into component parts.SDSCSECONDARY DIAGNOSIS CODED DUE TO SYSTEM CONSTRAINTDue to the system that the Organisation uses, codes are technically incorrect at some level, omitted or sequenced incorrectly. Primary procedure error key descriptions Coder Error PP3PRIMARY PROCEDURE INCORRECT AT THREE CHARACTER LEVELThe primary procedure code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at third character level and incorrectly sequenced within a secondary field.PP4PRIMARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVELThe primary procedure code has been allocated to an incorrect four character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at fourth character level and incorrectly sequenced within a secondary field.PPISPRIMARY PROCEDURE INCORRECTLY SEQUENCEDThe primary procedure or intervention code recorded by the auditor has been accurately coded but not sequenced as the primary procedure by the coder.PPOPRIMARY PROCEDURE OMITTEDThe primary procedure recorded by the auditor has not been recorded by the coder in any procedure field.PPNRPRIMARY PROCEDURE NOT RELEVANTThe primary procedure recorded by the coder is not relevant to the episode of care. Non-Coder Error PPIINFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODINGSee PDI.PPDPRIMARY PROCEDURE DOCUMENTATION ISSUEThe auditor is unable to code the clinical data from the source documentation and compare against that of the Trusts due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct The source documentation is illegible. PPM PRIMARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG.PPCPRIMARY PROCEDURE CODED TO CLINICIAN SPECIFICATIONThere is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures the intervention that occurred. For example: by unbundling diagnoses or procedures into component parts.PPSCPRIMARY PROCEDURE CODED DUE TO SYSTEM CONSTRAINTDue to the system that the Organisation uses codes are technically incorrect at any level, omitted or sequenced incorrectly. Secondary Procedure error key descriptions Coder Error SP3SECONDARY PROCEDURE INCORRECT AT THREE CHARACTER LEVELThe secondary procedure code has been allocated to an incorrect three character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at third character level and incorrectly sequenced.SP4SECONDARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVELThe secondary procedure code has been allocated to an incorrect four character code. Or, where it is clear the code allocated to classify the procedure or intervention is incorrect at fourth character level and incorrectly sequenced.SPISSECONDARY PROCEDURE INCORRECTLY SEQUENCEDThe Organisation has not sequenced the procedure coding according to the rules and conventions of the classification. For example: See use as secondary code when associated withSPOSECONDARY PROCEDURE OMITTEDSecondary procedure that has been recorded by the auditor as relevant but is missing from the Organisations recorded episode.SPNRSECONDARY PROCEDURE NOT RELEVANTThe secondary procedure code recorded by the coder is not relevant to the episode of care. Non-Coder Error SPIINFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF CODINGSee PDI.SPDSECONDARY PROCEDURE DOCUMENTATION ISSUEThe auditor is unable to code the clinical data from the source documentation and compare against that of the Trusts due to unclear or inconsistent information. For example: Inconsistency between information recorded by clinical staff contained on the source documentation and it is not clear which is correct The source documentation is illegible.SPMSECONDARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION There is a clear and documented directive from management to contravene coding to national standards. For example: by unbundling diagnoses or procedures into component parts by adding or optimising the coded clinical data to alter the derived HRG.SPCSECONDARY PROCEDURE CODED TO CLINICIAN SPECIFICATIONThere is a clear and documented directive from clinicians to contravene coding to national standards or capture those instances where a clinician has requested that coding be done in a particular way as it more accurately captures the intervention that occurred. For example: by unbundling diagnoses or procedures into component parts.SPSCSECONDARY PROCEDURE CODED DUE TO SYSTEM CONSTRAINTDue to the system that the Organisation uses codes are technically incorrect at any level, omitted or sequenced incorrectly. Appendix C - Analysis of Errors Number%Total number of episodes examined1000UTAUnsafe to Audit0Actual number of episodes examined1000Number or episodes where HRG would change as a result of the auditors codingNumber of primary diagnoses correct90990.9Non Coder ErrorPDIInformation not available at the time of coding101PDDPrimary Diagnosis Documentation issuePDMPrimary Diagnosis Coded to Management SpecificationPDCPrimary Diagnosis Coded to Clinician SpecificationPDSCPrimary Diagnosis Coded due to System ConstraintCoder ErrorPD3Primary Diagnosis Incorrect 3-character level252.5PD4Primary Diagnosis Incorrect 4-character level333.3PD5Primary Diagnosis Incorrect 5-character levelPDISPrimary Diagnosis Incorrectly Sequenced121.2PDOPrimary Diagnosis Omitted111.1Secondary DiagnosisNumber of secondary diagnoses5436Number of secondary diagnoses correct499391.9Non Coder ErrorSDIInformation not available at the time of coding110.2SDDSecondary Diagnosis Documentation issue40.1SDMSecondary Diagnosis Coded to Management SpecificationSDCSecondary Diagnosis Coded to Clinician SpecificationSDSCSecondary Diagnosis Coded due to System ConstraintCoder ErrorSD3Secondary Diagnosis Incorrect 3-character level601.1SD4Secondary Diagnosis Incorrect 4-character level510.9SD5Secondary Diagnosis Incorrect 5-character level80.1SDISSecondary Diagnosis Sequencing90.2SDOSecondary Diagnosis Omitted2614.8ECIExternal Cause Code Incorrect30.1ECOExternal Cause Code Omitted220.4 Number%Primary ProceduresNumber of primary procedures436Number of primary procedures correct40492.7Non Coder ErrorPPIInformation not available at the time of coding10.2PPDPrimary Procedure Documentation issuePPMPrimary Procedure Coded to Management SpecificationPPCPrimary Procedure Coded to Clinician SpecificationPPSCPrimary Procedure Coded due to System ConstraintCoder ErrorPP3Primary Procedure Incorrect 3-character level71.6PP4Primary Procedure Incorrect 4-character level40.9PPISPrimary Procedure Incorrectly Sequenced40.9PPOPrimary Procedure Omitted143.2Secondary ProceduresNumber of secondary procedures958Number of secondary procedures correct87591.3Non Coder ErrorSPIInformation not available at the time of coding10.1SPDSecondary Procedure Documentation issueSPMSecondary Procedure Coded to Management SpecificationSPCSecondary Procedure Coded to Clinician SpecificationSPSCSecondary Procedure Coded due to System ConstraintCoder ErrorSP3Secondary Procedure Incorrect - 3-character level40.4SP4Secondary Procedure Incorrect - 4-character level10.1SPISSecondary Procedure Incorrectly Sequenced10.1SPOSecondary Procedure Omitted767.9 Appendix D- List of Published References ICD-10 (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 2010 version) Volume 1, 2 and 3 OPCS-4.7 (Office of Population Censuses and Surveys, Version 4.7) Volume 1 and 2 The National Clinical Coding Standards Manual ICD-10 4th Edition book The OPCS-4.7 National Clinical Coding Standards book The Coding Clinic Collection The Data Quality Review Dataset Change Notices     PAGE  PAGE 6 Heart of England NHS Foundation Trust Clinical Coding Information Governance Audit 2015/16 ()]^vz{}   ۷{j[L;!h+8>hauB*CJOJQJphh+8>hBB*OJQJphh+8>hE~[B*OJQJph h+8>hE~[5B*OJQJphh+8>h ZB*OJQJphh+8>h0]B*OJQJphh+8>hB*OJQJphh+8>h& B*OJQJphh+8>hUB*OJQJph(h+8>h5B*CJ0OJQJaJ0ph(h+8>hU5B*CJ0OJQJaJ0phhkphUB*OJQJph()]^   ? 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