clinical coding paula wheeler, acc clinical coding service manager
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Clinical CodingPaula Wheeler, ACC
Clinical Coding Service Manager
What is Clinical Coding?
Translation of medical terminology written by a clinician to describe a patient’s:
Complaint
Problem
Diagnosis
Treatment
Reason for seeking medical attention
into a coded format which is nationally and internationally recognised
CLASSIFICATION CODING
The classifications used by this Trust for clinical coding are:
• ICD10 International Classification• Used to capture diagnostic clinical data• OPCS4 a UK specific classification• Used to capture surgical interventions and
procedures
Why do we code?
Clinical
Statistical
Clinical audit
Outcome
measurement
Cost analysis
Clinical Governance
ClinicalIndicators
Commissioning
Financial flows HRGs & PbR
Health trends
Informatio
n
Governanc
e
Epidemiology
Aetiology Casemix planning
Treatment effectiveness
Benchmarking
3 Languages of Health
• Terming
• Coding
• Grouping
SOURCE DOCUMENTATIONThe coding source documentation should be:
Accurate and complete
Avoid use of abbreviations
Clear and detailed
Legible and in indelible ink or typed
Reflect the patients episode of care
Co-morbiditiesThe hospital episode length of stay and co-morbidities can
affect the HRG allocation.• Epilepsy• Diabetes• Asthma• Hypertension• Heart conditionsRecently published guidance list of all co-morbidities that
must be coded when mentioned in the clinical record
Financial impact of Incomplete terming
• R00.2 (ICD10) Palpitations
• HRG 2015-2016 EB07I
• Arrhythmia or conduction disorders, without CC
• Tariff £617
Complete terming
• R00.2 (ICD10) Palpitations
• E11.9 (ICD10) Type 2 diabetes
• HRG 2015-2016 EB07H
• Arrhythmia or conduction disorders, with CC
• Tariff £1,695
Terming
R04.0 (ICD10) EpistaxisE05.1 (OPCS)Cauterisation of internal
noseHRG 2015-2016 CZ12YMinor Nose Procedures 19 years and
over without CCTariff £719
Be specific
• R04.0 (ICD10) Epistaxis
• E05.2 (OPCS) Ligation of artery of internal nose
• HRG 2015-2016 CZ15Q
• Complex Major Nose Procedures without CC
• Tariff £2,975
BENEFIT OF RICHER CODING
Finance InformationResearchCancer registry
Everyone benefits
Clinical Coding ContactsPaula Wheeler , Clinical Coding Service ManagerJo Counter, Clinical Coding Training ManagerAnn Buttle, Clinical Coding Data Analyst & AuditorMargaret Caldaralo, Team LeaderDaniel Whittaker, Team LeaderRichard Gale, Clinical Coding Auditor
Thank You
Any Questions?