Clinical Coding Audit Report Powys Teaching Health Board

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1 ` Clinical Coding Audit Report Powys Teaching Health Board Mrs Helen Anne Dennis ACC NHS Wales Informatics Service

2 CONTENTS Powys Teaching Health Board Clinical Coding Audit Report... 3 Executive Summary Introduction Aims Objectives Background Methodology Findings Conclusions Recommendations Page 2 of 48

3 Powys Teaching Health Board Clinical Coding Audit Report Executive Summary 1.1 Introduction This audit represents part of an ongoing series of clinical coding accuracy audit reports, produced as part of the NHS Wales Informatics Services national clinical coding audit programme. This programme was established following the completion of an initial all-wales audit of clinical coding accuracy that was undertaken in collaboration with Welsh Audit Office (WAO) in 2013/ The programme intends to identify areas of improvement or non-improvement following the recommendations given in those (and subsequent) audits This programme is being taken forward by the Informatics Service s Clinical Classifications Team and will ensure a continual ongoing programme of clinical coding accuracy audit across all Welsh Health Boards and NHS Trusts This report outlines the findings and recommendations of the Informatics Service s Clinical Classifications Team audit of clinical coding accuracy at Powys Teaching Health Board. 1.2 Methodology The sample audited was 105 Finished Consultant Episodes (FCEs), which were randomly generated from the activity data held within the Patient Episode Database for Wales (PEDW). Only FCEs from the specialties of General Medicine, General Surgery and Trauma & Orthopaedics were audited. The period audited covered episodes with an end date of 1 st November 2014 to 28 th February 2015 inclusive The locally assigned classification codes were audited against national clinical coding standards using the information available in the patients case notes and relevant electronic systems (e.g. RADIS) Attention was also paid to the patient case notes being used by the coders and auditors in order to assess their impact on the assignment of codes The episodes audited were limited to an episode length of ten days or less. Page 3 of 48

4 1.3 Findings The percentage of codes that were correct was above the recommended level in secondary diagnosis, primary procedures and secondary procedures but was below the recommended level in primary diagnosis. Below is a breakdown of the error rates: Code Type Primary Diagnosis Secondary Diagnosis Primary Procedure Secondary Procedure Total Number of Codes Reviewed Total Number of Correct Codes % % % % Percentage Correct When looked at by specialty, the percentage of correct codes is: Code Type Percent Correct in Percent Correct in Percent Correct in General Surgery General Medicine Trauma & Orthopaedics Primary Diagnosis 100% 71.88% 88.57% Secondary Diagnosis 92.31% 77.78% 85.71% Primary Procedure 97.22% 93.55% 94.12% Secondary Procedure 98.41% 96.67% 90.38% It should be noted that of the 105 episodes examined 66 (62.86%) contained no errors in any position The above figures represent an increase in the overall accuracy of clinical coded data at Powys Teaching Health Board since the previous audit in April 2014 (See Appendix 2) The percentage of correctly assigned codes in the General Medicine episodes was below the recommended level in primary and secondary diagnosis Despite a significant increase in the percentage of primary diagnosis correctly assigned within the Trauma and Orthopaedic episodes since the previous audit, it still failed to reach the recommended level Whilst not an issue affecting coding accuracy, it was noted by the auditor that there were some issues with the specialty patients are being admitted to in the Powys Teaching Health Board. One of the General Surgery episodes in the audit was a therapeutic termination of pregnancy, episodes when patients were admitted for a cystoscopy were admitted under the General Medicine specialty and patients who were admitted for carpal tunnel decompression were admitted under both general surgery and trauma and orthopaedics. Page 4 of 48

5 1.3.6 Case Note Findings: The case notes used in the audit were generally in a good condition. However the auditor found that even though there were dividers documents were sometimes filed out of order. There were a number of episodes where patients were having a check cystoscopy under the General Medicine specialty. These episodes often had no documented primary diagnosis. The indication for the admission was often documented as to come in for check cystoscopy. Some of these patients were referred from other sites and in these cases there was often very little relevant information within the medical record regarding the admission. In the majority of case notes the clinicians did not document comorbidities. The clinical coders capture any comorbidities using the General Practitioner s referral letter. The medical records for patients attending for endoscopies under the General Medicine specialty in most cases did not contain a discharge summary when they were coded. In cases where there was more than one finding on endoscopy there was no indication as to what was the primary diagnosis. 1.4 Conclusions The senior clinical coder and staff at the Powys Teaching Health Board have addressed many of the issues contributing to the errors found in the previous audit. This has resulted in an improvement in the overall quality of the clinical coded data at the Powys Teaching Health Board. In particular the coding of General Surgery episodes demonstrates a very high level of accuracy. The Powys Teaching Health Board clinical coding staff are up to date with their required training and generally demonstrate a sound grasp of national clinical coding rules and standards. As recommended in the previous audit report all the clinical coders at Powys Teaching Health Board have attended a Trauma and Orthopaedic workshop. Although the primary diagnosis figures still remains marginally below the recommended percentages, a significant improvement in the quality of the clinical coded data for this specialty can be observed. As was the case in the previous audit the coding of procedures was of a particularly high standard, exceeding the recommended levels of accuracy. The lack of clinical involvement in the clinical coding process, together with the lack of accurate discharge summaries and poor documentation for the endoscopy and cystoscopy episodes under the General Medicine specialty is making it difficult for the clinical coders to assign accurate codes for both primary and secondary diagnosis. There was some confusion among the clinical coding staff at Powys Teaching Health Board in regard to the definition of internal and external haemorrhoids. Together with the lack of a documented definitive primary diagnosis on the Page 5 of 48

6 endoscopy reports, this is resulting in the clinical coders failing to assign the codes to identify haemorrhoids in an accurate and consistent manner. Clinical staff are not documenting the relevant comorbidities in the medical record necessitating the use by clinical coders of the GP referral document to ascertain comorbidities. The use of this document as a sole source of information on comorbidities poses a risk to the accuracy of clinically coded data as there is no way to identify from it which of the listed comorbidities are relevant to the episode of care being coded. Whilst the clinical coding staff at Powys Teaching Health Board are fully up to date with the necessary level of core clinical coding training, the lack of staff with the ACC qualification prevents the organisation from being assured that its coding staff are coding to a recognised national standard and makes it impossible to ascribe a base line level of expertise to the clinical coders at Powys Teaching Health Board. 1.5 Recommendations The clinical coding staff at the Powys Teaching Health Board should be congratulated on the improvements made since the previous audit and should continue to aim for further improvement. The clinical coding staff at Powys teaching Health Board should continue to attend regular training sessions in order to maintain their skills. The Senior Clinical Coder at Powys Teaching Health Board should seek to meet with clinicians with the aim of discussing options for improving the quality of the documentation within the medical record. In particular it is suggested that the Health Board s admission proformas should be updated to contain a field explicitly identifying the primary diagnosis for the episode. The Senior Clinical Coder at Powys Teaching Health Board should meet with the clinical coding staff to clarify the standards to be applied when coding haemorrhoids. The creation of a local clinical coding policy to formally outline the way in which codes are assigned to haemorrhoids within the next 3 months is recommended. The Senior Clinical Coder should encourage dialogue between clinicians and clinical coding staff at Powys Teaching Health Board. It is advised that the senior clinical coder should seek to plan awareness sessions for the clinical staff on the importance of complete and accurate clinical documentation to clinical coding accuracy. The Senior Clinical Coder, together with the Head of Information for Powys Teaching Health Board, should meet with representatives of the clinical staff to request that relevant co morbidities are documented in the medical record. Thus eliminating the use by clinical coders of the General Practitioners referral letter as a means of obtaining this information Page 6 of 48

7 The clinical coders at Powys Teaching Health Board should be encouraged to seek clinical clarification when there is a lack of, or conflicting information in the medical notes. Powys Teaching Health Board should continue to support, encourage and fund clinical coding staff to sit the National Clinical Coding Qualification. Page 7 of 48

8 2 Introduction 2.1 The Admitted Patient Care data set (APC ds), and the clinically coded data contained within, is arguably the single most important source of management information in use within NHS Wales. The availability of timely, complete, accurate-coded APC data are an essential pre-requisite for numerous current and emerging decision support processes. 2.2 Welsh LHBs and Velindre NHS Trust are mandated to clinically code the finished consultant episodes (FCEs) for every patient admitted to a Welsh NHS hospital. Organisations are required to accurately code information relating to all diagnoses and procedures relevant to each individual episode of care experienced by a patient. 2.3 Welsh LHBs and Velindre Trust are currently monitored against two national performance measures of clinical coding completeness. These are: 95% of all FCEs are clinically coded within 3 months of the episode end date; 98% of all FCEs are clinically coded for any given rolling 12 month period. 2.4 There are currently no national performance indicators or measures for clinical coding accuracy. 2.5 Clinical coded data are used for a variety of uses and it impacts on a number of areas including: Healthcare planning (including service reconfiguration); Performance management (notably the production of Tier 1 and other Welsh Government performance indicators and measures); Providing the basis of the Risk Adjusted Mortality Index (RAMI), a current WG priority area. Health needs assessment; Evaluation of treatment and outcome analysis; Benchmarking; Chronic disease management (and the linkage of datasets); Provision of information for research; The production of official statistics and ad-hoc requests; Financial costing and resource utilisation mapping; Ad hoc requests (be they Ministerial, AQs, media/public and so on); Identification of at risk populations; Identification of frequency and occurrence of disease; The monitoring of (often high cost) services provided by the Welsh Health Specialised Services Committee (WHSSC); Clinical coding data is central to a range of national information initiatives, such as the annual financial costing process and patient-level costing It is current WG policy for healthcare data to be made more readily available to the general public, media etc. under its transparency agenda. Where clinical coding information is being shared, this will further raise the importance of that data being accurate and the need for the Service to be assured that this is the case. 2.6 It is a therefore a requirement that clinical coded data are accurate, consistent, complete and coded in a timely fashion. Page 8 of 48

9 2.7 Clinical coding audit is currently the only means by which it is possible to assure the accuracy of clinical coded data. 2.8 This is the second round of audits and will complete this first audit cycle. The NHS Wales Informatics Service (NWIS) Clinical Classifications Team is carrying out a programme of audit of clinical coding accuracy (i.e. the assignment of ICD-10 and OPCS-4 classifications codes by Welsh clinical coding staff) across Wales. 2.9 This report outlines the findings and recommendations of the NHS Wales Informatics Service (NWIS) Clinical Classifications Team audit of clinical coding accuracy at Powys Teaching Heath Board. The audit was carried out between the 3 rd August and 6 th August 2015 and was undertaken by an Accredited Clinical Coder from NHS Wales Informatics Service. 3 Aims 3.1 The aim of this audit was to assess the accuracy of the clinically coded data produced by Powys Teaching Health Board by comparing the codes assigned by the clinical coding department against national clinical coding standards. 3.2 This report aims to provide a benchmark that can be used by the clinical coding department within Powys Teaching Health Board, to identify areas for improvement within the organisation and aid in the identification and planning of future training needs. Conclusions and recommendations based on areas of both good and poor practice found are provided to achieve this. 3.3 It also aims to evaluate the quality of the source documentation used by the coders and the local policies and procedures used at Powys Local Health Board. 4 Objectives 4.1 The objectives for the audit were: To assess the clinical coding data against national clinical coding standards; To identify and report areas of good and bad practice; To review and assess the accuracy of the source documentation used for clinical coding; To assess the level of clinical involvement with the coding department and to what degree this impacts on the coding process and coding accuracy; To make recommendations designed to support future improve in the accuracy of clinically coded data within the hospital; Highlight training issues within the department. Page 9 of 48

10 5 Background 5.1 The Powys Teaching Health Board has a total of ten hospitals offering a variety of patient services. Four of these hospitals have a clinical coder working on site: Bronllys Hospital, Llanidloes War Memorial Hospital, Ystradgynlais Community Hospital and Llandrindod Wells County War Memorial Hospital. Since patients of Powys Teaching Health Board can move between hospitals a patient s coding can be carried out by any of these clinical coders. 5.2 The clinical coding department sits under the planning and performance directorate at Powys Teaching Health Board. 5.3 The clinical coding department has a Clinical Coding Policy Document which was last updated in July There have no local clinical coding policies at present. 5.4 Demographics & Staffing Powys Teaching Health Board generated a total of 4885 Finished Consultant Episodes (FCEs) in the 2013/14 financial year Clinical coding staff at Powys Teaching Health Board assigns codes to episodes from all 10 community hospital sites within the Health Board In addition to inpatient coding the clinical coding staff at Powys Teaching Health Board also assign classification codes to some Consultant outpatient episodes and nurse led clinics Powys Teaching Health Board achieved 99.1% completeness for clinical coding as of the submission date at the end of July There was a total establishment of 2.08 WTE band 4 coders across the health board. Since 26th August 2013 there has been a band 5 Senior Clinical Coder in post, based at Llandrindod Wells hospital, at 0.73 WTE. There is also a full time (1 WTE) Information Manager, based at Bronllys Hospital, who has overall responsibility for the clinical coding service at Powys Teaching Health Board. Band Whole Time Equivalents (WTE) by Site Total 4 Bronllys, Llanidloes, Ystradgynlais Llandrindod Wells Hospital During the period being audited there were no WTE vacancies within the coding department of Powys Teaching Health Board Coders range in experience in the coding department from nine to seventeen years as coders The Powys Teaching Health Board has one coder situated in each of the four base hospitals within the Health Board. Bronllys Hospital, Llanidloes War Memorial Hospital, Ystradgynlais Community Hospital and Llandrindod Wells County War Memorial Hospital. Page 10 of 48

11 5.4.9 During the period of time examined by this audit the coding department had no backlog. 5.5 Workloads The clinical coding staff at Powys Teaching Health Board have no recommendation of an expected number of episodes to code per year During the period being audited, there was no overtime worked by the clinical coders at Powys Teaching Health Board and no use made of clinical coding contractors In addition to the coding of inpatient and day case episodes the clinical coding staff at Powys Teaching Health Board also code outpatient attendances. Exact figures of outpatient episodes coded annually were not available to the auditor There are no figures available with regard to the numbers of episodes coded by the individual coders employed at Powys Teaching Health Board. 5.6 Training None of the clinical coding staff at the Powys Teaching Health Board hold the ACC qualification. However the Senior Clinical Coder is at present studying in preparation to sit the examination in March The department is also in the process of recruiting a trainee coder for whom the willingness to work toward the NCCQ qualification is part of their contract of employment All of the coders meet the minimum training requirements of having completed the Clinical Coding Foundation Training Course and a Clinical Coding Refresher Training Course within the last 3 years There is currently no NCS approved Clinical Coding Trainer or Auditor on site. All the department s training needs are currently met by D&A Consulting; a commercial company supplying clinical coding training that provides all training services to NHS Wales via a national training contract agreed with NHS Wales Informatics Service. 5.7 Assignment of codes Clinical Codes are input directly into the Myrddin Patient Administration system. Codes are assigned to episodes using both the ICD-10 4th Edition and OPCS 4.6 classifications. Clinical coding staff does not make use of any form of electronic encoding software to support their entry of clinical codes into Myrddin The inpatient and day case episodes that require coding are identified by a link person who runs weekly reports from within the reporting module in Myrddin. The medical notes are then collected by the link person and delivered to the relevant clinical coding department. Ward attendee s requiring coding are forwarded by the ward staff and outpatient attendances that require coding are provided by patient services staff The primary source documentation used by the coders, in most cases, is the written patient case notes. Use is also made of various electronic systems to supply Page 11 of 48

12 supporting clinical information, such as histopathology reports and the results of CT and MRI scans. It is rare for clinical coders to have access to typed discharge summaries The clinical coding staff does not make use of read codes, clinical terms or SNOMED-CT. 5.8 Previous Audits and Recommendations The last external audit was carried out in April 2014 by the Richard Burdon ACC AND Helen Dennis ACC from NHS Wales Informatics Service, they presented a formal audit report to the UHB and a copy was also sent to the Wales Audit Office and the Welsh Government, which recommended that: Clinical coding staff should continue to attend regular training sessions in order to maintain their skills. Monthly clinical coding staff meetings should be introduced at the earliest opportunity. The clinical coders should be encouraged to bring any examples of complex coding for investigation at this forum in order to maximise learning across the team. Clinical coding staff should attend the next available Trauma & Orthopaedics specialist training course. Prior to an official training course clinical coding staff might benefit from visiting other Welsh hospitals where spinal procedures are carried out in order to expand their knowledge. The Senior Clinical Coder needs to ensure regular contact with each of the clinical coders and encourage open dialogue with regard to clinical coding queries. The LHB would benefit from developing a process by which regular audits of the work of each coder could be carried out, with the results fed back to them as part of a regular PDR programme. Clinical coding staff should engage with lead clinicians within each specialty in order to begin a program of clinical validation of coded data. The coding manager should discuss with the appropriate departments the possibility of coders attending departmental meetings, MDTs etc. as a link between the department and clinical staff. The clinical coders should also be encouraged to return notes to clinicians when there is a lack of, or conflicting, information in the medical notes. Powys Teaching Health Board should immediately begin to support, encourage and fund clinical coding staff to sit the National Clinical Coding Qualification The Senior Clinical Coder at Powys Teaching Health Board is at present planning to carry out regular audits of the work of the clinical coders and using the results to inform the individuals personal development review. Page 12 of 48

13 5.8.3 The only form of data quality checks that are at present carried out at Powys Teaching Health Board on clinical coded data in the validation at source (VAS) checks carried upon submission of data to PEDW by the health board s information department. Details of any errors identified by this source are returned to the individual coder for investigation and corrected it required. 6 Methodology 6.1 A pre-audit questionnaire regarding details of the organisation of clinical coding services in the LHB was completed by the Clinical Coding Manager. 6.2 A list of 358 FCEs, drawn from three specialties, was randomly generated from the Patient Episode Database for Wales (PEDW) the national database of APC ds activity data. PEDW is managed and maintained by NWIS. 6.3 The planned number of episodes audited was 35 from each of the 3 specialties below: General Medicine General Surgery Trauma and Orthopaedic. 6.4 The episodes audited were limited to those with an episode end date of 1 st November 2014 and 28 th February 2015 inclusive. 6.5 The episodes audited were limited to an episode length of ten days or less. 6.6 Unfortunately due to the small numbers of General Medicine episodes at the Llandrindod site of the Powys Teaching Health Board and the difficulty sourcing the medical records the auditor was only able to analyse 32 episodes from this specialty the extra 3 episodes needed to make up the required 105 were taken from the general surgery specialty. 6.7 Staff at Powys Local Health Board was required to provide the auditors with access to the written case note records associated with the requested FCEs. 6.8 The clinical coding record for each episode was generated from the hospital s clinical coding encoder software and a copy attached to the relevant set of case notes. 6.9 The auditors then assessed the locally coded data against the National Clinical Coding Standards (see Appendix 1) and the Welsh Clinical Coding Standards (see Appendix 2) using ICD-10 and OPCS 4.6 classifications Codes were audited as one of 4 types: Primary Diagnosis codes (i.e. the main condition treated); Secondary Diagnosis codes (including External Cause Codes and Morphology Codes); Primary Procedure codes; Secondary Procedure codes (including Chapter Z site codes) Any errors were assigned to an Error Type (see Appendix 3), which specified the exact nature of the error. This information was then tabulated to calculate the statistical information required (see Appendix 2) Page 13 of 48

14 6.12 The errors are of two general types non-coder errors and coder errors. Non-coder errors are those errors identified as being due to a factor external to the individual coder, such as an encoder system which automatically re-sequences codes, or a local coding policy which instructs the coder to assign codes in a way which contravenes national standards. Coder errors are errors in the coding made by the coder themselves For statistical reasons and due to the judgemental nature of a code being relevant to an episode, those error types where coding staff have assigned more codes than the auditor deems relevant (i.e. overcoding ) are not counted as errors when calculating the error percentages. However, the numbers of these errors are reported and examples given for information and training purposes An analysis of the errors is given in Appendix The recommended minimum percentage of correct codes are: 90% for Primary Diagnosis and Primary Procedure 80% for Secondary Diagnosis and Secondary Procedures The Accredited Clinical Coding (ACC) exam also stipulates a minimum requirement of 90% accuracy for all clinical coding staff sitting the National Clinical Coding Qualification (NCCQ) exam. Furthermore, the above targets are consistent with the requirements set out in the NHS England Information Governance Toolkit requirement 505 (attainment level 2) and audits of coded data carried out by NCS auditors on English Coders Case notes which did not contain the episode to be audited were marked as Unsafe To Audit (UTA) and removed from the sample and replaced A total of 105 episodes were examined. 7 Findings 7.1 The percentages of correctly assigned codes are given below: Code Type Total Number of Total Number of Percentage Correct Codes correct codes Primary Diagnosis % Secondary Diagnosis % Primary Procedure % Secondary Procedure % The percentage of codes that were correct was above the recommended level in secondary diagnosis, primary procedure and secondary procedures but was below the recommended level in primary diagnosis. 7.2 When looked at by specialty, the percentage of correct codes is: Code Type Percent Correct in Percent Correct in Percent Correct in Page 14 of 48

15 General Surgery General Medicine Trauma & Orthopaedics Primary Diagnosis 100% 71.88% 88.57% Secondary Diagnosis 92.31% 77.78% 85.71% Primary Procedure 97.22% 93.55% 94.12% Secondary Procedure 98.41% 96.67% 90.38% It should be noted that of the 105 episodes examined 66 (62.86%) contained no errors in any position. 7.3 The above figures represent an increase in the overall accuracy of clinical coded data at Powys Teaching Health Board since the previous audit in April 2014 (See appendix 2). 7.4 The percentage of correctly assigned codes correct in the General Medicine episodes was below the recommended level in primary and secondary diagnosis. 7.5 Despite a significant increase in the percentage of primary diagnosis correctly assigned within the Trauma and Orthopaedic episodes since the previous audit; it still failed to reach the recommended level. 7.6 Whilst not an issue affecting coding accuracy, it was noted by the auditor that there were some issues with the specialty are being admitted to in the Powys Teaching Health Board. One of the General Surgery episodes in the audit was a therapeutic termination of pregnancy, episodes when patients were admitted for a cystoscopy were admitted under the General Medicine Specialty and patients who were admitted for carpal tunnel decompression were admitted under both general surgery and trauma and orthopaedics. 7.7 Unsafe to Audit (UTA) There were no episodes which were marked as UTA. Page 15 of 48

16 7.8 Primary Diagnosis Codes The primary diagnosis was correct in 87.62% of the episodes audited (92 of the 105 primary diagnoses). These were broken by specialty as follows:- General Surgery primary diagnosis correct 100% (38 out of the total of 38) General Medicine primary diagnosis correct 71.88% (23 out of the total of 32) Trauma and Orthopaedic primary diagnosis correct 88.57% (31 out of the total of 35) A breakdown of the errors in primary diagnoses by their associated error types is given below (see Appendix 3 for a detailed explanation of the error keys): Error Type Number of Errors Percentage of FCEs with Error PD % PD % PD5 1.95% PDIS 1.95% PDI 1.95% PDD % Primary Diagnosis Incorrect at 3 rd Character Level (PD3) There were three primary diagnosis errors (2.86%) incorrect at 3 rd character level. Example: LHB Coding Z47.0 Follow up care involving removal of fracture plate and other internal fixation T84.8 Other complications of internal orthopaedic prosthetic devices, implants and grafts R52.9 Pain, unspecified G56.0 Carpal tunnel syndrome Auditor Coding T84.1 Mechanical complication of internal fixation device of bones of limb G56.0 Carpal tunnel syndrome The information within the medical record stated that the screws from the internal fixation were prominent. Therefore the code Z47.0 should not be used as there is a complication code which should be coded in preference. Ref: Persons encountering health services for specific procedures and health care (Z40 Z54) National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page XXI-8 Page 16 of 48

17 7.8.2 Primary Diagnosis Incorrect at 4th Character Level (PD4) There were four primary diagnosis errors (3.81%) incorrect at 4 th character level. Example: LHB Coding Auditor Coding K29.7 Gastritis, unspecified K29.6 Other gastritis B98.0 Helicobacter pylori [H.pylori ] as the cause of diseases classified to other chapters B98.0 Helicobacter pylori [H.pylori ] as the cause of diseases classified to other chapters I10.X Essential (primary) hypertension I10.X Essential (primary) hypertension The National Clinical Coding Standards ICD-10 4th Edition (April 2014) states that the correct code assignment for H pylori associated gastritis is K29.6 Other gastritis together with B98.0 Helicobacter pylori [H. Pylori] as the cause of diseases classified to other chapters. Ref: Gastritis and duodenitis (K29) National Clinical Coding Standards ICD-10 4th Edition (April 2014), page XI Primary Diagnosis Incorrect at 5th Character Level (PD5) There was one primary diagnosis error (0.95%) incorrect at 5 th character level. Example: LHB Coding Auditor Coding M23.23 Derangement of meniscus due to old tear or injury, Medial collateral ligament or other and unspecified medial meniscus horn of medial meniscus M23.34 Other meniscus derangements Lateral collateral ligament or anterior horn of lateral meniscus M17.9 Gonarthrosis, unspecified M17.9 Gonarthrosis, unspecified M23.22 Derangement of meniscus due to old tear or injury Posterior cruciate ligament or posterior M23.34 Other meniscus derangements Lateral collateral ligament or anterior horn of lateral meniscus The information within the medical record stated that the tear was on the posterior horn of the medial meniscus. Clinical coding standards state that coders should accurately code each problem to the furthest level of specificity. Ref: Uniformity National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page 5 Ref: Three dimensions of coding accuracy. Individual codes National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page 5 Page 17 of 48

18 7.8.4 Primary Diagnosis Incorrectly Sequenced (PDIS) There was one primary diagnosis error (0.95%) which was incorrectly sequenced. Example: LHB Coding Auditor Coding M17.9 Gonarthrosis, unspecified M23.89 Other internal derangements of knee, Unspecified ligament or unspecified meniscus M23.89 Other internal derangements of knee, M17.9 Gonarthrosis, unspecified Unspecified ligament or unspecified meniscus M67.2 Synovial hypertrophy, not elsewhere M67.2 Synovial hypertrophy, not elsewhere classified classified Although the patient did have gonarthrosis in addition to torn articular cartilage the main condition treated was the cartilage tear. Ref: General Coding Standards. Primary diagnosis National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page Information available at the time of audit not available at the time of coding (PDI) There was one primary diagnosis error (0.95%) due to information being available to the auditors that was not available at the time of coding. Example: LHB Coding Auditor Coding K20.X Oesophagitis K21.0 Gastro-oesophageal reflux disease with oesophagitis J44.9 Chronic obstructive pulmonary disease, J44.9 Chronic obstructive pulmonary disease, unspecified unspecified K29.9 Gastroduodenitis, unspecified K29.9 Gastroduodenitis, unspecified I10.X Essential (primary) hypertension I10.X Essential (primary) hypertension E11.9 Non-insulin-dependent diabetes mellitus There was a discharge letter which was written some months after the episode had been coded which gave the diagnosis for this episode of care as gastro-oesophageal reflux disease with oesophagitis. Ref: General Coding Standards. Primary diagnosis National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page 9 Ref: Uniformity National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page 5 Ref: Three dimensions of coding accuracy. Individual codes National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page Primary Diagnosis Documentation Issue (PDD) Page 18 of 48

19 There were three primary diagnosis errors (2.86%) due to documentation issues. Example: LHB Coding Auditor Coding N30.9 Cystitis, unspecified Z08.9 Follow up examination after unspecified treatment for malignant neoplasm J45.9 Asthma, unspecified Z85.5 Personal history of malignant neoplasm of the urinary tract J45.9 Asthma, unspecified The documentation in these notes was very confusing. There was recent information which stated that the patient had indeed recently suffered from cystitis. But there was other documentation within the medical record which showed that the check cystoscopy for which the patient had been booked was being carried out because of a previous personal history of Transitional Cell Carcinoma of the bladder. Therefore the main reason for care was to check that the bladder was still free of recurrence. Ref: General Coding Standards. Primary diagnosis National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page Secondary Diagnosis Codes Including External Cause and Morphology Codes The secondary diagnoses codes were 83.91% correct (146 out of the total 174 secondary diagnoses). These were broken down by specialty as follows: General Surgery secondary diagnosis correct 92.31% (36 out of the total of 39) General Medicine secondary diagnosis correct 77.78% (56 out of the total of 72) Trauma and Orthopaedic secondary diagnosis correct 85.71% (54 out of the total of 63) A breakdown of the errors by their associated error types is given below (see Appendix 3 for detailed explanation of error keys): Error Key Number of Errors Percentage of Secondary Diag with Error SD % SDNR % SDO % SDI 1.57% Page 19 of 48

20 7.9.1 Secondary Diagnosis Incorrect at 4 rd Character Level (SD4) There were three secondary diagnoses (1.72%) incorrect at 4 th character level. Example: LHB Coding A09.9 Gastroenteritis and colitis of unspecified origin K92.2 Gastrointestinal haemorrhage, unspecified I84.2 Internal haemorrhoids without complication Auditor Coding A09.9 Gastroenteritis and colitis of unspecified origin K92.2 Gastrointestinal haemorrhage, unspecified I84.9 Unspecified haemorrhoids without complication The clinician did not state that the haemorrhoids were internal. Therefore the code for unspecified haemorrhoids without complication should have been assigned. Ref: Uniformity National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page 5 Ref: Three dimensions of coding accuracy. Individual codes National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page Secondary Diagnosis Not Relevant (SDNR) There were four secondary diagnoses assigned which were not relevant 2.29%. Example: LHB Coding Z47.0 Follow up care involving removal of fracture plate and other internal fixation T84.8 Other complications of internal orthopaedic prosthetic devices, implants and grafts R52.9 Pain, unspecified G56.0 Carpal tunnel syndrome Auditor Coding T84.1 Mechanical complication of internal fixation device of bones of limb G56.0 Carpal tunnel syndrome Although pain was documented in the medical notes it was caused by the complication of the internal fixation therefore the assignment of the code R52.9 Pain, unspecified was not required. Ref: Coding Standards. Recording signs and symptoms. National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page XVIII-2 Page 20 of 48

21 7.9.3 Secondary Diagnosis Omitted (SDO) There were twenty three secondary diagnoses (13.22%) omitted. Example: LHB Coding Auditor Coding M23.23 Derangement of meniscus due to old M23.23 Derangement of meniscus due to old tear tear or injury, Medial collateral ligament or or injury, Medial collateral ligament or other and other and unspecified medial meniscus unspecified medial meniscus I10.X Essential (primary) hypertension I10.X Essential (primary) hypertension J45.9 Asthma, unspecified J45.9 Asthma, unspecified E11.9 Non-insulin-dependent diabetes mellitus The information in the medical record stated that the patient had a co-morbidity of type II diabetes. This is an important co-morbidity and should have been coded as the clinical coding standards state that diabetes will always influence the care process. Ref: Diabetes mellitus (E10 E14) National Clinical Coding Standards ICD-10 4 th Edition (April 2014), page IV Information available at the time of audit not available at the time of coding (SDI) There was one secondary diagnosis error (0.57%) due to information being available to the auditors that was not available at the time of coding. Example: LHB Coding Auditor Coding M70.6 Trochanteric bursitis M70.6 Trochanteric bursitis S32.50 Fracture of pubis closed M84.35 Stress fracture, not elsewhere classified pubis I48.X Atrial fibrillation and flutter I48.X Atrial fibrillation and flutter Z92.1 Personal history of long-term (current) use of anticoagulants Z92.1 Personal history of long-term (current) use of anticoagulants J45.9 Asthma, unspecified J45.9 Asthma, unspecified The information available at the time of coding stated insufficiency fracture which is not indexable in ICD-10. There was however no indication of an external cause which would be required for a traumatic fracture. There was a discharge letter in the medical record which was dated after the clinical codes had been assigned which stated stress fracture. Page 21 of 48

22 7.10 Primary Procedure Codes There were 101 primary procedure codes assigned. The primary procedure was correct in 95.05% of the episodes audited (96 of the 101 primary procedures). These were broken down by specialty as follows: General Surgery primary procedures correct 97.22% (35 out of the total of 36) General Medicine primary procedures correct 93.55% (29 out of the total of 31) Trauma and Orthopaedic primary procedures correct 94.12% (32 out of the total of 34) A breakdown of the errors by their associated error types are shown below (see Appendix 3 for detailed explanation of the error keys): Error Key Number of Errors Percentage of Primary Procedures with Error PP % PP % Primary Procedure Incorrect at 3 rd Character Level (PP3) There were three primary procedures (2.97%) incorrect at 3 rd character level. Example: LHB Coding Auditor Coding S45.4 Removal of organic material from skin S44.2 Removal of metal from skin NEC Z50.1 Skin of arm Z50.1 Skin of arm Z94.2 Right sided operation Z94.2 Right sided operation Y82.2 Injection of local anaesthetic Y82.2 Injection of local anaesthetic The information in the medical record stated the procedure was the removal of a metal fragment from the skin of arm which should be coded to S44.2. Clinical coding standards state that each procedure should have the correct code assignment and that each procedure should be coded to the furthest level of specificity. Ref: Data Quality. Uniformity. National Clinical Coding Standards OPCS-4.7 (April 2014) page 8 Ref: Data Quality. Three dimensions of coding accuracy. Individual codes. National Clinical Coding Standards OPCS-4.7 (April 2014) page 9 Page 22 of 48

23 Primary Procedure Incorrect at 4 th Character Level (PP4) There were two primary procedures (1.98%) incorrect at 4 th character level. Example: LHB Coding Auditor Coding H25.9 Diagnostic endoscopic examination of H25.1 Diagnostic endoscopic examination of lower bowel using fibreoptic sigmoidoscope lower bowel and biopsy of lesion of lower bowel Unspecified using fibreoptic sigmoidoscope O30.2 Splenic flexure Z28.5 Descending colon The information in the medical record showed that during the endoscopic examination the patient had a biopsy of the descending colon therefore code H25.1 should have been assigned. Ref: Data Quality. Uniformity. National Clinical Coding Standards OPCS-4.7 (April 2014) page 8 Ref: Data Quality. Three dimensions of coding accuracy. Individual codes. National Clinical Coding Standards OPCS-4.7 (April 2014) page 9 Ref: GCS10: Coding endoscopic procedures National Clinical Coding Standards OPCS-4.7 (April 2014) page Secondary Procedure Codes There were 197 secondary procedures codes assigned. These secondary procedure codes were 93.91% correct (185 out of the 197 secondary procedures). They were broken down by specialty as follows: General Surgery secondary procedure correct 98.41% (62 out of the total of 63) General Medicine secondary procedure correct 96.67% (29 out of the total of 30) Trauma and Orthopaedic secondary procedure correct 90.38% (94 out of the total of 104) A breakdown of the errors by their associated error types are shown below (see Appendix 3 for detailed explanation of error keys): Error Key Number of Errors Percentage of Secondary Procedures with Error SP3 2.57% SP % SPO % Page 23 of 48

24 Secondary Procedure Incorrect at 3 rd Character Level (SP3) There were two secondary procedures (0.57%) incorrect at 3 rd character level. Example: LHB Coding Auditor Coding H25.9 Diagnostic endoscopic examination of H25.1 Diagnostic endoscopic examination of lower bowel using fibreoptic sigmoidoscope lower bowel and biopsy of lesion of lower bowel Unspecified using fibreoptic sigmoidoscope O30.2 Splenic flexure Z28.5 Descending colon The information in the medical record showed that during the endoscopic examination a biopsy was carried out. The coder failed to assign the code for the site of the biopsy and instead coded the furthest point examined. The clinical coding standards state that site of the biopsy takes presidency over the furthest point examined. Therefore the site code should be Z28.5 Descending colon. Ref: GCS10: Coding endoscopic procedures National Clinical Coding Standards OPCS-4.7 (April 2014) page Secondary Procedure Incorrect at 4 th Character Level (SP4) There was one secondary procedure (1.02%) incorrect at 4 th character level. Example: LHB Coding Auditor Coding T59.2 Excision of ganglion of hand NEC T59.2 Excision of ganglion of hand NEC Z94.2 Right sided operation Z94.3 Left sided operation Y82.2 Injection of local anaesthetic NEC Y82.2 Injection of local anaesthetic NEC The information in the medical record showed that the operation was carried out on the left side. The clinical coding standards state that each procedure should have the correct code assignment and be coded to the furthest level if specificity. Ref: Data Quality. Uniformity. National Clinical Coding Standards OPCS-4.7 (April 2014) page 8 Ref: Data Quality. Three dimensions of coding accuracy. Individual codes. National Clinical Coding Standards OPCS-4.7 (April 2014) page 9 Ref; ChSZ1: Use of codes in chapter Z National Clinical Coding Standards OPCS-4.7 (April 2014) page 122 Page 24 of 48

25 Secondary Procedure Omitted (SPO) There were nine secondary procedures (4.57%) omitted. Example: LHB Coding Auditor Coding W82.2 Endoscopic resection of semilunar W82.2 Endoscopic resection of semilunar cartilage cartilage W83.6 Endoscopic excision of articular W83.6 Endoscopic excision of articular cartilage cartilage NEC NEC Z94.3 Left sided operation Z76.5 Lower end of femur Y80.4 Intravenous anaesthetic NEC Z94.3 Left sided operation Y80.4 Intravenous anaesthetic NEC The information in the medical record stated that the excision was from the articular cartilage on the femur. The clinical coding standards state codes from chapter Z should be assigned when this adds further information about the site of the procedure. Therefore the code for the site of lower end of femur should have been assigned. Ref:ChSZ1: Use of codes in chapter Z National Clinical Coding Standards OPCS-4.7 (April 2014) page 122 Ref: CSZ1: Site codes National Clinical Coding Standards OPCS-4.7 (April 2014) page Case Note Findings The case notes used in the audit were generally in a good condition. However the auditor found that even though there were dividers documents were sometimes filled out of order. The auditors encountered the following issues: There were a number of episodes where patients were having a check cystoscopy under the General Medicine specialty. These episodes often had no documented primary diagnosis. The indication for the admission was often documented as to come in for check cystoscopy. Some of these patients were referred from other sites and in these cases there was often very little relevant information within the medical record regarding the admission. In the majority of cases the clinicians did not document comorbidities. The clinical coders capture any co morbidities using the General Practitioner s referral letter. The medical records for patients attending for endoscopies under the General Medicine specialty in most cases did not contain discharge summaries when they were coded. In cases where there was more than one finding on the endoscopy sheet there was no indication as to what was the primary diagnosis. 8 Conclusions Page 25 of 48

26 8.1 The Senior Clinical Coder and staff at the Powys Teaching Health Board have addressed many of the issues contributing to the errors found in the previous audit. This has resulted in an improvement in the overall quality of the clinical coded data at the Powys Teaching Health Board. In particular the coding of General Surgery episodes demonstrates a very high level of accuracy. 8.2 The Powys Teaching Health Board clinical coding staff are up to date with their required training and generally demonstrates a sound grasp of national clinical coding rules and standards. 8.3 As recommended in the previous audit all the clinical coders at Powys Teaching Health Board have attended a Trauma and Orthopaedic workshop. Although the primary diagnosis figures still remains marginally below the recommended percentages, a significant improvement in the quality of the clinical coded data for this speciality can be observed. 8.4 As was the case in the previous audit the coding of procedures was of a particularly high standard, exceeding the recommended levels of accuracy. 8.5 The lack of clinical involvement in the clinical coding process together with the lack of accurate discharge summaries and poor documentation for the endoscopy and cystoscopy episodes under the General Medicine specialty is making it difficult for the clinical coders to assign an accurate code for both primary and secondary diagnosis. 8.6 There was some confusion among the clinical coding staff at Powys Teaching Health Board in regard to the definition of internal and external haemorrhoids. Together with the lack of a documented definitive primary diagnosis on the endoscopy reports, this is resulting in the clinical coders failing to assign the codes to identify haemorrhoids in an accurate and consistent manner. 8.7 The Clinical staff are not documenting the relevant comorbidities in the medical record necessitating the use by clinical coders of the GP referral document to ascertain comorbidities 8.8 Whilst the clinical coding staff at Powys Teaching Health Board are fully up to date with the necessary level of core clinical coding training, the lack of staff with the ACC qualification prevents the organisation from being assured that its coding staff are coding to a recognised standard and makes it impossible to ascribe a base line level of expertise to the clinical coders at Powys Teaching Health Board. 9 Recommendations 9.1 The clinical coding staff at the Powys Teaching Health Board should be congratulated on the improvements made since the previous audit and should continue to aim for further improvement. 9.2 The clinical coding staff at Powys Teaching Health Board should continue to attend regular training sessions in order to maintain their skills. 9.3 The Senior Clinical Coder at Powys Teaching Health Board should seek to meet with clinicians with the aim of discussing options for improving the quality of the documentation within the medical record. In particular it is suggested that the Health Page 26 of 48