Clinical Coding is "the translation of medical terminology as written by
the clinician to describe a patient's complaint, problem, diagnosis,
treatment or reason for seeking medical attention, into a coded format"
which is nationally and internationally recognised.
It is usually done after the patient has been discharged and there are
strict deadlines that need to be adhered to for data submission.
▪ Spell = A patient’s hospital stay from
the point of admission to discharge
▪ During their stay, a patient may
under the care of different
consultants. This may be due to a
change in shift, ward or specialty.
▪ Finished Consultant Episode (FCE) =
the time period under each
consultant.
▪ A spell can be made up of single or
multiple FCEs.
Clinical Coders code diagnoses, co-morbidities, complications and any procedures undertaken for each FCE.
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▪ All Care delivered during a patient episode is documented in
the patient notes.
▪ Once the episode is complete, the notes are sent to clinical
coding – where trained clinical coders carefully read through
the notes and allocate the appropriate alphanumeric codes.
▪ For diagnoses, they use the International Classification of
Diseases 10th Edition (ICD-10), which comprises over 16000
codes.
▪ For procedures and operations, the OPCS Classification of
Interventions and Procedures version 4.9 which has over
4000 codes.
▪ The codes are entered in computer software which
determines the healthcare resource group (HRG) most, but
not all HRGs have an associated tariff.
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▪ A Healthcare Resource Group (HRG) is a grouping of diagnoses &/or
procedures which are similar in terms of care delivered and the resource
used.
▪ In order to reflect the complexity of care delivered, HRGs capture:
▪ Main condition treated/investigated
▪ Procedures/investigations performed
▪ comorbidities
▪ complications
▪ Age
▪ length of stay
▪ HRGs offer organisations the ability to understand their activity in terms of
the types of patients they care for and the treatments they undertake.
▪ Clinical coding provides the information that underpins almost all the data
flows within the hospital.
▪ It can be used for:
▪ Clinical Governance: Clinical Audit, Risk Analysis, Mortality data
▪ Quality Improvement: Improving patient pathways, clinical research,
treatment effectiveness
▪ Epidemiology: Health trends, Etiology studies, clinical indicators
▪ Benchmarking: Reducing variation, model hospital
▪ Commissioning: casemix planning, development of new services
▪ Financial Flows: National Tariff Income, Cost Analysis
▪ Coders are only able to use information that has been documented in the
clinical notes. Incomplete or unclear documentation has been repeatedly
shown as a weak link in the data quality chain.
Top Coding Tips:
Make Sure the Coding Team know where key information is
recorded
Accessible Paper Notes – Medical/Nursing Notes/AHP and ensure filed
appropriately
Electronic: - If using different software packages, what info is
recorded where
Future-Focused Finance is a national programme designed to engage everyone in improving NHS Finance to support the delivery of quality services for patients. We want to bring finance staff at all levels of the profession together with the
teams we work with in our own organisations and make sure that everyone has access to skills, knowledge, methods and opportunities to influence the decisions affecting our services. We believe by working together in this way we can
harness our diverse and talented NHS workforce to produce high quality services and reduce waste in NHS spending.
The programme consists of national and regional events, networks, resources and talent development programmes – all designed to advance the understanding of finance in the NHS. Underpinning all of our work are commitments to value
the diversity within NHS finance teams and to challenge behaviours that contribute to inequality in accessto development and opportunities for some.
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