Published: 03/11/2005 Volume 115 No. 5980 Page 10 11

Despite the heightened importance of the role, clinical coders remain underpaid and undervalued. Daloni Carlisle highlights their plight and ponders what the future holds for them

Clinical coders ought to be watching their star rise right now. Payment by results is rolling out and putting them in the spotlight, a revised coding system is on its way, as is a new national coding strategy.

Instead, the profession (such as it is) finds itself under immense pressure. Under-staffed, underpaid, under-trained and demoralised. PbR seems to be killing coders.

'In this country it is not a profession, ' says Sue Eve-Jones, joint founder of the new Professional Association of Clinical Coders.

'There is no career structure and the pay is lousy, ' she says.

Yes, she concedes, there is a nationally recognised qualification - the National Clinical Coding Qualification set up in 1999 - but no requirement for coders to hold it nor financial reward for those that do.

'There are a few 'supercoders' who are heads of department in large trusts but for most people the career ladder stops in middle management on a salary between£25,000 and£40,000, ' she adds.

Does any of this matter?

According to the Audit Commission it does. In its 2004 report Introducing Payment by Results, the commission identified 'weaknesses in the recruitment, training and leadership of clinical coding staff' as one of the risks to PbR.

A year on, there remains a serious recruitment issue in some parts of the country - notably London. It is being fuelled by discrepancies in Agenda for Change gradings.

Barts and the London trust director of clinical information Alaric Cundy explains: 'Payment by results has made clinical coding more important and That is put the pressure on to make sure teams are established or even increased in size.

There are not enough people in the pool to fill the posts available.' As a result, he says, trusts are taking a lax view of the Agenda for Change guidelines and advertising for staff with no qualifications. 'This is compromising the efforts we have put in to improving standards.'

Exams cancelled Where trusts are pushing their staff to become accredited coders things are not easy. Since 2001, the NCCQ exam has been run just once a year.

NHS Connecting for Health and the Institute of Health Record and Information Management - which administers and awards the NCCQ - have cancelled next year's exam altogether, except for resits, because a new surgical clinical coding system is due for implementation in April 2006.

'But this not going to be a wholesale rewrite, ' says Mr Cundy.

'We are looking at a new version of the exam so the justification for cancelling this year has gone.' There are also wide regional variations. While clinical coders without a qualification can get a grade 4 salary in London (starting around£16,000), elsewhere there are hospital trusts paying grade 2 (more like£11,000).

'It makes it very difficult to recruit people with the intellect to do the job, ' adds Ms Eve-Jones. 'It is a double whammy in that unqualified people are recruited who are not at the right level to do the job.' This is just the start of the pressures created by PbR. At a recent HSJ conference, Lynn Bracewell, NHS classifications service manager at NHS CfH, warned that competent staff are leaving coding because of the practices being asked of them.

She cited coding managers asked to code rather than manage; qualified coders asked to chase case notes; departments that have stopped professional development altogether.

The most controversial and high profile of these is upcoding - the generally accepted definition of which is misuse of standardised codes to obtain more money.

Ms Bracewell maintained that coding managers are under 'significant pressure' to upcode. The issue is a bone of contention between more than one primary care trust and the NHS, with allegations of upcoding being countered by defences of increasingly complex clinical case-mix (HSJ news page 9, September 15).

Certainly the Department of Health is alert to the practice. The PbR draft code of conduct currently out for consultation proposes to get trusts to sign up to a statement that their coding will be 'prompt, fair and accurate'. An assurance framework to monitor and audit upcoding is in development, with stakeholders including the Audit Commission and the NHS Counter Fraud Service.

It is expected to set out just what might constitute upcoding and the penalties its detection will incur.

Early lessons

To date, the evidence of upcoding in the NHS is scant. 'We looked at this early this year and found no evidence, ' says Dr Paul Aylin, clinical lecturer at Imperial College London.

His team compared coding in foundation trusts and NHS trusts in 2004-05, looking for 'healthcare resource group drift'. If trusts were manipulating the codes you might expect to see an increase in codes that indicate more complications and therefore attract a higher tariff. There was no change.

Dr Aylin warns: 'That is not to say it [upcoding] doesn't exist. It may start to show up later.' Ms Eve-Jones is also sceptical about the upcoding brouhaha. 'If a coder has a query about what code to use there is an attitude of 'will we get paid more if we use one over the other?'' she says.

'But I do not get the sense of real pressure in this area.' Attempts to maximise income in this way might be misguided anyway. Firstly, there is an audit system developed by the old NHS Information Authority that would rapidly detect systematic upcoding.

Secondly, it might be counterproductive in some instances. 'We have uncovered some interesting phenomena, ' says Mr Cundy. 'There are several cases where adding complications changes the HRG but reduces the income.' He adds: 'We have alerted the HRG team to this.

But the result is that reference costs are not consistent and have been translated into national tariffs that are not consistent. It is a big mess.' What is clear is that more information is being recorded in the hospital episode statistics, says Dr Aylin. 'HES offers around 14 fields for diagnoses. The first is the primary diagnosis; the rest are secondary or comorbidities. Many more diagnoses are being entered.' 'It is not necessarily a bad thing, ' says Dr Aylin. 'It is only bad if it is falsely coding.' Ms Eve-Jones recognises the phenomenon. 'When I started in coding, we were clearly told to code just the things that were relevant to that episode of care. Now in many places coders are being asked to record everything - the fact that the patient who had a total hip replacement also has asthma and ischaemic heart disease.

'It is a way of capturing information about that patient. The other side is that there are certain HRGs that change with comorbidities and that influences income.' In other words, improved coding might be the basis of their PCT's accusation of upcoding.

Ms Eve-Jones add: 'But there are no rules about when to record comorbidities. You cannot accuse someone of upcoding if there are no rules. This needs to be sorted out.' Of much more immediate concern to many coders and coding managers is the issue of deadlines. 'The huge pressure is to get through the workload, ' says Ms Eve-Jones. 'The directors of finance are saying they do not care how; coders need to get the coding done to meet the deadlines for the payment system. Most people care and want to do a good job. This is where they are being demoralised.' Ms Bracewell recognises all this.

She hopes a national coding strategy - work on which is only just under way - will start to map out how these concerns might be resolved.

In the meantime, trusts must invest in their coding staff, she says, and use their qualified staff appropriately. They should encourage collaboration between coding, information, finance managers and medical directors.

For their part, coders need to get involved with tariff setting. They need to resist the pressure to change codes but log discrepancies with the PbR team.

Mr Cundy sums up the pressure.

'We have got time to act now to get some of this right, ' he says. 'But we are going to have to be quick.' .

Key points

The Audit Commission has said weaknesses in the recruitment, training and leadership of clinical coders is a risk to payment by results.

Hospitals are struggling to recruit people to the job because of low pay and lack of career structure.

Anecdotal evidence suggests coders are under 'significant' pressure to misuse codes for more money.