Published: 22/04/2002, Volume II4, No. 5902 Page 44

If the US experience is anything to go by, NHS clinical coders' roles will soon be elevated from clerical to professional, says Homer Warner Jr

The introduction of a casemix prospective payment system in the US over 20 years ago brought about a dramatic change in the number, quality and status of the clinical coder.

Coding was no longer just about aggregating statistics, it was about getting paid. The UK's move to case-mix budgeting under payment by results may have a similar evolutionary impact on coders.

As the NHS adopts case-mix budgeting, clinical coding accuracy will become more important than ever.

Accurate coding increases the effectiveness of many national agendas in addition to the financial flows initiative, including performance assessment, national service frameworks, clinical indicators, clinical governance and data accreditation.

To support the financial flows scheme, it will be important to ensure clinical coders have access to proper training and pass the accredited clinical coder exam.

The role of the clinical coder will need to be elevated from clerical to professional status.

Clinical coders in the US, where case-mix reimbursement under diagnostic-related groups has been in place since 1983, work in partnership with clinicians to ensure that documentation and coding are consistent, accurate and complete.

Close partnerships between coders and clinicians/clinical teams is essential to ensure coding accuracy.

Clinical coding is much more complex than merely assigning a code to a term. As defined by the NHS Clinical Coding Instruction Manual, it is the translation of clinical statements into a form that can be easily tabulated, aggregated and sorted for clinical analysis in an efficient and meaningful manner. Use of encoding software is widely considered a means of increasing coding accuracy.

Industry experts strongly suggest that using non-clinical personnel for coding, however, requires proper training and testing, career paths and competitive salaries to assure coder retention. In addition, training in formal and systematic auditing procedures and the use of tools to provide guidelines and prompts is required.

My own US and UK research supports this. A sample consisting of 238 hospitals was selected from a pool of 5,691 US acute care hospitals. At each, health information management directors and coding supervisors were asked about clinical coding practices.

In the UK, three separate coding surveys were conducted over a two-year span, with 105 clinical coding managers from 50 per cent of acute care trusts across the UK.

Immediate differences were found. Encoder software was used by 90 per cent of US coders, 70 per cent of whom held the minimum professional credentials, compared to software used by 50 per cent of UK coders, of whom just 11 per cent had the minimum credentials.

Recruiting experienced/trained coders and coder retention were by far the most common problems. Only one-third of UK coding managers surveyed said they were fully or adequately staffed and 66 per cent claimed to be short of at least one coder, a significant increase on the previous year.

With 21,000 clinical coders, the US has over twice the number of coders per 100 acute care beds than the UK. Likely reasons for this include the breadth of clinical events that US coders are asked to code, case-note size and the actual number of pages per record (which has increased fourfold in 20 years). A significant amount of time is also spent querying clinicians and following up on 'problem' cases.

The role of the clinical coder in the UK has only recently begun to show signs of moving from clerical to professional status.

Under Agenda for Change, higher pay is being considered for coding credentials and an increasing, though still relatively small, number of coders are seeking accreditation (11 per cent).

By comparison, over 70 per cent of US acute care coders have certified coding specialist status.

As coding is one rung on the health information management ladder, many go on to become health information managers, technicians or administrators.

Salary surveys indicate that certification is reflected in wages.

According to one source, salaries for certified coders are nearly $10,000 more than salaries for non-certified coders. A positive correlation with US salaries and coder credentials implies that with credentials comes higher quality work deserving higher pay.

Higher salaries for coders who are accredited and who have proven experience are now being considered in the NHS by the National Clinical Classifications Service.

But the number of coders per acute trust will need to at least double in the coming years if coders are expected to do more work, improve accuracy and meet monthly reporting deadlines.

A professional career path for coders must be established in the UK in order to recruit capable people into this field, either within the NHS Information Authority or through the existing university system.

The NHS will need to hire more coders with ACC credentials and then pay them appropriately higher wages.

Homer Warner Jr works in international business development and market research for 3M Health Information Systems.