In the first of a series on the importance of data, Paul Robinson looks at the issues surrounding clinical coding

In this first article, I want to concentrate on the issue of data quality and why it is important for non-executives to concern themselves with this level of detail.

The Healthcare Commission recently announced that it would be investigating mortality rates at Mid Staffordshire foundation trust - a potential cause for concern for any non-executive. While the exact causes have yet to be established, the trust has already said it believes the problem lies in its clinical coding.

Clinical coding is the foundation on which a trust's performance and ability to compete and operate within NHS guidelines is built. If it is inaccurate, a trust may not only get a completely false picture, it may be giving its strategic health authority and other providers a false picture as well.

There are two key elements added by coders - diagnosis and procedure codes. Without these codes, there is no record of what the patient's presenting condition was or what help was given to them - nor is there any possibility of assigning a tariff to enable the recovery of costs.

The introduction of payment by results has put pressure on clinical coding services because trusts want to ensure that costs are recovered for as many patients as possible.

Coding problems

The exact pathway of clinical coding varies between organisations but usually relies on a coder (employed as a relatively low grade member of clerical staff) taking information from the medical record, where it has often been written by the most junior doctor. This pathway can take several weeks, leading to delays in coding and subsequent problems.

The level of tariff frequently depends on the complexity of the patient's presenting condition and this can only be properly ascertained if the full range of considered diagnoses are recorded and coded.

In our experience of carrying out clinical coding reviews, we have found that the majority of trusts are under-coding complexity and therefore getting lower tariffs than they should be.

Likewise, when looking at mortality rates, any risk adjustment model relies on an understanding of how sick the patient who died was. This is drawn from the diagnostic codes. A single diagnostic code gives the presenting condition but not any co-morbidities that may have been present. Therefore, the depth of coding is of particular importance for comparative mortality assessments.

Getting it right

Getting clinical coding right affects a trust's income, how they appear when they are compared to other providers, and the ability to conduct research and monitoring across the NHS.

One of the keys to improving clinical coding is greater involvement by clinicians. Generally, coders are quite accurate, but the information they rely on is not always complete. The Information Centre for health and social care is working with the Royal College of Physicians to try to increase clinicians' involvement.

Many trusts have put a lot of effort into improving this vital area, but there are still a significant number with problems. If more is not done, there is a risk that, in the era of payment by results, the financial viability of the NHS depends on the most junior doctor and a clerical officer.

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