Clinical Coding Audit

Accuracy of Clinical Coding in Acute General Surgical Admissions is Improved by Collaboration Between Clinicians and Clinical Coders

Aims: Accurate clinical coding is necessary to ensure correct diagnoses are recorded and HRG codes generated. Healthcare resource allocation, finance and epidemiological studies depend upon this process being robust. Aims were to assess the accuracy of the coding of emergency general surgical admissions and to highlight areas for improvement within the coding process.

The study of clinical coding was run by the NWRC and reviewed the coding of acute surgical admissions between 1st March and 15th August 2013 from seven hospital trusts in the Northwest. 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.

This study involved 20 surgical trainees, 7 clinical coders and was overseen by a consultant surgeon. Of 208 cases of emergency surgical admissions. 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”.

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. It is important for surgical trainees to develop and understanding of the clinical coding process and the impact of the accuracy of the documentation has, not only on financial tariffs but on the allocation of healthcare resources and public health records.

This project was successfully presented as oral presentations at the ASGBI 2015 and 2016. The finished manuscript was published in the Journal of Surgical Research. The links below will take you to these resources:

N.A Heywood, M.G., N Charlwood, R Brindle, Accuracy of Clinical Coding in Acute General Surgical Admissions is Improved by Collaboration between Clinicians and Clinical Coders. British Journal of Surgery, 2015. 102(s1): p. 9-118 (Short papers, Emergency surgery 0932, page 50).

DOI: 10.1002/bjs.9729

Heywood NA, Gill MD, Charlwood N, Brindle R, Kirwan CC, Allen N, et al. Improving accuracy of clinical coding in surgery: collaboration is key. Journal of Surgical Research. 2016;204(2):490-5.

doi:  10.1136/bmjquality.u202053.w1990