The other week my colleague Laura Hickey talked about her life as a clinical coder. It is now my turn to try and describe my role as a clinical coding auditor.
As Laura explained, clinical coding is the translation of medical and surgical information into codes. We use classifications to assign the codes; ICD-10 for diagnosis codes and OPCS for procedure codes. It is the coding auditor’s job to check the work of clinical coders to ensure they have assigned these codes correctly, assessing and if necessary re-coding patient episodes using national standards.
We do this to help hospitals get their clinical information as accurate as possible for all its uses. The main focus of clinical coding in recent years is financial, as coded date is used to determine how much money a hospital receives for each patient it treats. However, the accuracy of clinical coding will affect mortality rates and other performance indicators that hospitals are measured against, as well as the clinical decisions made based on this data.
The path to becoming a clinical coding auditor is long and sometimes feels tortuous. First you have to get your NCCQ (National Clinical Coding Qualification) and then submit a CV, provide evidence of your report writing skills and sit an exam… and that is all before you are allowed to go onto the auditor course! Once you get on the course you learn about the audit methodology, such as how to assign error keys. These keys are the way coding errors are classified and can be very confusing to non coders who don’t know their PD4s from a PPD.
If you don’t know, PD4 describes an error in the primary diagnosis at the fourth character level, and can have an impact on payment if the patient does not have surgery in hospital. For example, E103 is the diagnosis code for a patient with type 1 diabetes with ophthalmic complications. If this should have been recorded as type 1 diabetes with neurological complications (diagnosis code E104), this would be an error at fourth character level (PD4). Even such a small change can impact on payment, with the hospital receiving £579 for the neurological complications diagnosis instead of £392 for the one with ophthalmic complications.
PPD on the other hand describes an error with the main surgical procedure caused by issues in the source documentation used for coding. For example, total hip replacements usually involve the surgeon cementing both parts of the prosthetic hip in place, whereas only one part is cemented in a hybrid hip replacement. This needs to be clearly stated in the notes to be coded correctly. There is a difference in payment between these two operations of around £600 per patient. If this is a consistent error the cost to the hospital will soon mount up!
As you can imagine, being a coding auditor means I really have to understand all the nuances of coding so that I can spot as many errors as possible. However, some errors are more easily identified than others. I once audited a dentist performing heart transplants! The diagnosis code for dental cavities is K029, but this was being entered as the procedure code by mistake. K029 is the procedure code for a heart transplant. Such a simple mistake can have such a huge impact.
Having worked as a clinical coding auditor at an NHS hospital the change to become an external auditor for CHKS was a big one. I am now based at home and not in a coding department, which was a bit strange at first. However, we audit in pairs so when we are on site so there is always another experienced auditor with you to bounce ideas off. And support is still there over the phone or via email. As the Professional Lead for Audit I support our audit team and help them with any queries they might have. The other major change is the travelling. I travel to sites by car, or train, or even aeroplane. I do end up staying away, but I get the time back at home, which makes for a good balance.
CHKS delivers coding audit services across the whole of the United Kingdom, and working at so many sites across the country you realise how much variation there is in the process of coding. A big part of external audit is understanding how each coding department operates. Source documentation can range from three foot high multi-volume case notes to a paperless electronic patient record (EPR) – most organisations are somewhere between the two. Some coders code on the ward on a nurses station with no designated workspace. At other organisations coders don’t leave the office and never speak to front line staff. Neither situation supports accurate coding.
We also look at the policies and procedures documents the coding department work to, what training is available to coders, and what arrangements the trust has in place to review their own coding This understanding and background knowledge helps me to understand why the errors we find are happening, and allows me to feedback my findings in a way that enables organisations to improve the accuracy of their data.
It isn’t all about finding errors though. Visiting all of the different organisations also uncovers some really good coding practice which I can often share with others either on site or when writing my reports. Our work looking at clinical coding for Monitor and the Department of Health has shown a steady improvement in the accuracy of coding. These days errors are just as likely to be caused by problems with documentation than by mistakes made by the coders.
Some hospitals code from discharge letters or coding proformas rather than the full medical record. This is being accepted as a necessary evil as the workload increases and deadlines get tighter. However, the standard of these vary greatly with some a comprehensive summary of the patients stay and others leaving you wondering if they are writing about the same patient!
Incomplete information is something that we struggle to quantify in audit. We can only audit against what is written in the medical record. If it isn’t written down it cannot be coded. Or audited. That’s why we encourage clinician engagement, so they understand how their notes are being interpreted, and the impact this has an their data. When there is confidence in the information available to coders there can be a lot more confidence in the coding
The variety of work is what I enjoy most about my job. There are always different pieces of work from week-to-week. I don’t just audit inpatient coding audit – I’ve looked at outpatient, A&E and critical care data as well. I also look at activity carried out by private hospitals. The private providers are a lot different to the NHS. Most don’t have an A&E for a start and you miss out on reading about some of the peculiar reasons for attending! The case notes are a lot nicer too. No searching through eight volumes of records for something to audit, where the vital piece of information we need is actually written on the back of a letter from 1986 and looks more like a treasure map.
At the end of an audit I hold an end of audit meeting. The Coding Manager attends to get the draft results and go through the findings with me, but anybody from the organisation can be involved. I usually have to tailor my post audit wash–up meeting depending on who attends. If I am feeding back to a room full of finance managers or clinicians I don’t want to be discussing the coding guidance around open and closed manipulations of fractures or the changes to the rules around coding post operative complications.
All of the findings and results will be brought together in the report which I write at home. When the report is agreed everything is done and it is on to the next audit. As I write this my next audit will be on cardiology activity. Hopefully there won’t be another talented dentist at this hospital…
About the coding and and financial assurance team at CHKS
We are the largest private provider of healthcare clinical coding and data quality services in the UK. Our focus is on data and payment accuracy in healthcare. For more information about CHKS Clinical Coding, Data Quality and Financial Assurance Services, please click here.
Why not have a listen to a selection of views from clinical coders across the UK at our recent data quality and clinical coding conference? *** ADD LINK TO TO YOUTUBE VIDEO https://www.youtube.com/watch?time_continue=1&v=eHNGHaRSWrY***he other week my colleague Laura Hickey talked about her life as a clinical coder. It is now my turn to try and describe my role as a clinical coding auditor.
As Laura explained, clinical coding is the translation of medical and surgical information into codes. We use classifications to assign the codes; ICD-10 for diagnosis codes and OPCS for procedure codes. It is the coding auditor’s job to check the work of clinical coders to ensure they have assigned these codes correctly, assessing and if necessary re-coding patient episodes using national standards.
We do this to help hospitals get their clinical information as accurate as possible for all its uses. The main focus of clinical coding in recent years is financial, as coded date is used to determine how much money a hospital receives for each patient it treats. However, the accuracy of clinical coding will affect mortality rates and other performance indicators that hospitals are measured against, as well as the clinical decisions made based on this data.
The path to becoming a clinical coding auditor is long and sometimes feels tortuous. First you have to get your NCCQ (National Clinical Coding Qualification) and then submit a CV, provide evidence of your report writing skills and sit an exam… and that is all before you are allowed to go onto the auditor course! Once you get on the course you learn about the audit methodology, such as how to assign error keys. These keys are the way coding errors are classified and can be very confusing to non coders who don’t know their PD4s from a PPD.
If you don’t know, PD4 describes an error in the primary diagnosis at the fourth character level, and can have an impact on payment if the patient does not have surgery in hospital. For example, E103 is the diagnosis code for a patient with type 1 diabetes with ophthalmic complications. If this should have been recorded as type 1 diabetes with neurological complications (diagnosis code E104), this would be an error at fourth character level (PD4). Even such a small change can impact on payment, with the hospital receiving £579 for the neurological complications diagnosis instead of £392 for the one with ophthalmic complications.
PPD on the other hand describes an error with the main surgical procedure caused by issues in the source documentation used for coding. For example, total hip replacements usually involve the surgeon cementing both parts of the prosthetic hip in place, whereas only one part is cemented in a hybrid hip replacement. This needs to be clearly stated in the notes to be coded correctly. There is a difference in payment between these two operations of around £600 per patient. If this is a consistent error the cost to the hospital will soon mount up!
As you can imagine, being a coding auditor means I really have to understand all the nuances of coding so that I can spot as many errors as possible. However, some errors are more easily identified than others. I once audited a dentist performing heart transplants! The diagnosis code for dental cavities is K029, but this was being entered as the procedure code by mistake. K029 is the procedure code for a heart transplant. Such a simple mistake can have such a huge impact.
Having worked as a clinical coding auditor at an NHS hospital the change to become an external auditor for CHKS was a big one. I am now based at home and not in a coding department, which was a bit strange at first. However, we audit in pairs so when we are on site so there is always another experienced auditor with you to bounce ideas off. And support is still there over the phone or via email. As the Professional Lead for Audit I support our audit team and help them with any queries they might have. The other major change is the travelling. I travel to sites by car, or train, or even aeroplane. I do end up staying away, but I get the time back at home, which makes for a good balance.
CHKS delivers coding audit services across the whole of the United Kingdom, and working at so many sites across the country you realise how much variation there is in the process of coding. A big part of external audit is understanding how each coding department operates. Source documentation can range from three foot high multi-volume case notes to a paperless electronic patient record (EPR) – most organisations are somewhere between the two. Some coders code on the ward on a nurses station with no designated workspace. At other organisations coders don’t leave the office and never speak to front line staff. Neither situation supports accurate coding.
We also look at the policies and procedures documents the coding department work to, what training is available to coders, and what arrangements the trust has in place to review their own coding This understanding and background knowledge helps me to understand why the errors we find are happening, and allows me to feedback my findings in a way that enables organisations to improve the accuracy of their data.
It isn’t all about finding errors though. Visiting all of the different organisations also uncovers some really good coding practice which I can often share with others either on site or when writing my reports. Our work looking at clinical coding for Monitor and the Department of Health has shown a steady improvement in the accuracy of coding. These days errors are just as likely to be caused by problems with documentation than by mistakes made by the coders.
Some hospitals code from discharge letters or coding proformas rather than the full medical record. This is being accepted as a necessary evil as the workload increases and deadlines get tighter. However, the standard of these vary greatly with some a comprehensive summary of the patients stay and others leaving you wondering if they are writing about the same patient!
Incomplete information is something that we struggle to quantify in audit. We can only audit against what is written in the medical record. If it isn’t written down it cannot be coded. Or audited. That’s why we encourage clinician engagement, so they understand how their notes are being interpreted, and the impact this has an their data. When there is confidence in the information available to coders there can be a lot more confidence in the coding
The variety of work is what I enjoy most about my job. There are always different pieces of work from week-to-week. I don’t just audit inpatient coding audit – I’ve looked at outpatient, A&E and critical care data as well. I also look at activity carried out by private hospitals. The private providers are a lot different to the NHS. Most don’t have an A&E for a start and you miss out on reading about some of the peculiar reasons for attending! The case notes are a lot nicer too. No searching through eight volumes of records for something to audit, where the vital piece of information we need is actually written on the back of a letter from 1986 and looks more like a treasure map.
At the end of an audit I hold an end of audit meeting. The Coding Manager attends to get the draft results and go through the findings with me, but anybody from the organisation can be involved. I usually have to tailor my post audit wash–up meeting depending on who attends. If I am feeding back to a room full of finance managers or clinicians I don’t want to be discussing the coding guidance around open and closed manipulations of fractures or the changes to the rules around coding post operative complications.
All of the findings and results will be brought together in the report which I write at home. When the report is agreed everything is done and it is on to the next audit. As I write this my next audit will be on cardiology activity. Hopefully there won’t be another talented dentist at this hospital…
About the coding and and financial assurance team at CHKS
We are the largest private provider of healthcare clinical coding and data quality services in the UK. Our focus is on data and payment accuracy in healthcare. For more information about CHKS Clinical Coding, Data Quality and Financial Assurance Services, please click here.
Why not have a listen to a selection of views from clinical coders across the UK at our recent data quality and clinical coding conference?
The other week my colleague Laura Hickey talked about her life as a clinical coder. It is now my turn to try and describe my role as a clinical coding auditor.
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