Better clinical coding saves valuable time and money

More accurate clinical coding can lead to more effective use of resources and help hospitals cope better during the economic downturn, according to a group of U.K. researchers.

Clinical coding-the process by which information in clinical case notes is translated into codes, which are then stored in a hospital database-is the most crucial step in hospitals getting paid, either by the state or by insurers, for their activity, noted Dr. Nikolaos Koutroumanos and Dr. Julie Cox, radiologists at the University Hospital of North Durham.

“Healthcare institutions, whether state- or privately funded, are not exceptions to the current increasing fiscal pressures in our economy,” Koutroumanos noted at this year’s U.K. Radiological Congress. “Through effective and accurate clinical coding, everyone can play a role in healthcare economics, resulting in more sustainable allocation of resources.”

The duo sought to evaluate the accuracy of clinical coding for interventional radiological procedures. They asked their hospital’s information department for a list of patients whose clinical codes included the words “stent” and “angioplasty.”

They identified 136 procedures and found data for 129 cases between April 2005 and March 2008. They compared the actual “elective” or “nonelective” status to the way it had been coded from the request card/case notes (i.e., actual status) and coding data (i.e., coded status). In each case, they identified which tariffs were assigned.

Of the 25 emergency procedures, 93% were accurately coded. Overall, the audit revealed a loss of £14,112 (about €15,650) due to inaccurate coding. They offered 10 practical tips for improving clinical coding and helping your hospital through the credit crunch:

• Write legibly in all hospital documentation (case notes, discharge letters, etc.);
• Clearly document your name so that any queries can be directed to you; • Include data and time of entry and/ or any procedures undertaken;
• If you are not sure about what you are writing, ask a senior colleague; • If a patient has had a transfer of care, tell the hospital ward clerk;
• Make sure that case notes always follow the patient around the hospital; • Always record diagnoses, investigations, and procedures undertaken, and be as specific as you can in both case notes and discharge summaries;
• Don’t give a “?” diagnosis. If you’re not sure, ask. If no one is sure, report the symptoms. They can be coded too;
• Avoid or explain abbreviations. Remember that coding staff are not clinicians; and
• When completing electronic or paper pro formas, fill in all the gaps. They are included for a reason.