Clinical Coding
Paula Wheeler, ACC
Clinical Coding Service Manager
What is Clinical Coding?
Translation of medical terminology written by a
clinician to describe a patient’s:
 Complaint
 Problem
 Diagnosis
 Treatment
 Reason for seeking medical attention
into a coded format which is nationally and
internationally recognised
CLASSIFICATION CODING
The classifications used by this Trust for clinical
coding are:
• ICD10 International Classification
• Used to capture diagnostic clinical data
• OPCS4 a UK specific classification
• Used to capture surgical interventions and
procedures
Why do we code?
Treatment
effectiveness
Clinical audit
Commissioning
Clinical
Benchmarking
Statistical
Health trends
Clinical
Indicators
3 Languages of Health
• Terming
• Coding
• Grouping
SOURCE DOCUMENTATION
The coding source documentation should be:
 Accurate and complete
 Avoid use of abbreviations
 Clear and detailed
 Legible and in indelible ink or typed
 Reflect the patients episode of care
Co-morbidities
The hospital episode length of stay and comorbidities can affect the HRG allocation.
• Epilepsy
• Diabetes
• Asthma
• Hypertension
• Heart conditions
Recently published guidance list of all comorbidities that must be coded when
mentioned in the clinical record
Financial impact of
Incomplete terming
• R00.2 (ICD10) Palpitations
• HRG 2015-2016 EB07I
• Arrhythmia or conduction disorders, without
CC
• Tariff £617
Complete terming
•
•
•
•
•
R00.2 (ICD10) Palpitations
E11.9 (ICD10) Type 2 diabetes
HRG 2015-2016 EB07H
Arrhythmia or conduction disorders, with CC
Tariff £1,695
Terming
R04.0 (ICD10) Epistaxis
E05.1 (OPCS)Cauterisation of internal
nose
HRG 2015-2016 CZ12Y
Minor Nose Procedures 19 years and
over without CC
Tariff £719
Be specific
• R04.0 (ICD10) Epistaxis
• E05.2 (OPCS) Ligation of artery of internal
nose
• HRG 2015-2016 CZ15Q
• Complex Major Nose Procedures without
CC
• Tariff £2,975
BENEFIT OF RICHER CODING
 Finance
 Information
 Research
 Cancer registry
Everyone benefits
Clinical Coding Contacts
Paula Wheeler , Clinical Coding Service Manager
Jo Counter, Clinical Coding Training Manager
Ann Buttle, Clinical Coding Data Analyst & Auditor
Margaret Caldaralo, Team Leader
Daniel Whittaker, Team Leader
Richard Gale, Clinical Coding Auditor
Thank You
Any Questions?
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