regional clinical coding policy...clinical coding is the translation of medical terminology that...

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Title

Regional Clinical Coding Policy

Summary Clinical coding is the allocation of diagnostic and procedural coding to

clinical records in accordance with national standards and classification

rules and conventions as set out in the WHO ICD, National Clinical

Coding Standards ICD and OPCS and publications of the Coding Clinic.

This policy sets out the high level requirements for clinical coding to

ensure compliance with standards, accuracy and consistency of

information produced during the clinical coding process.

Operational

Date

1st May 2019

Review Date May 2020

Version

Number

3.0

Supersedes Policy and Procedure Document for Clinical Coding (2012)

Other

sources

Clinical Coding SharePoint site:

https://hscb.sharepoint.hscni.net/sites/pmsi/clinicalcoding/SitePages/Home.as

px

Information Standards & Data Quality SharePoint site:

https://hscb.sharepoint.hscni.net/sites/pmsi/isdq/SitePages/Home.aspx

Clinical Coding Performance Monitoring Definitions

Regional Clinical Coding Training Programme

Clinical Coding Training Procedures & Forms

https://hscb.sharepoint.hscni.net/sites/pmsi/clinicalcoding/SitePages/Home.aspx

https://hscb.sharepoint.hscni.net/sites/pmsi/clinicalcoding/SitePages/Home.aspx

https://hscb.sharepoint.hscni.net/sites/pmsi/isdq/SitePages/Home.aspx

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Version History

Date Version Author Comments

Jul-17 1.0 Lisa Whyte

Nov-18 2.0 Lisa Whyte Updates to the meeting section to

reflect new information governance

structures both regionally and

nationally.

Mar-19 3.0 Lisa Whyte Policy Statement – reference to new programmes of work such as encompass. Staffing – amended to reflect structure only required within the policy but more detailed staffing information in a separate document. Clinical Coding Procedures – clarification that this is the recommendation but that alternative processes must be documented. Audit – updated to reflect Trust audit information may be held in a separate document. Wording updated to reflect comments from SET & ST.

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Approval Process

Organisation Date

HSCB 8th March 2019

Belfast Trust 12th March 2019

SE Trust 12th March 2019

Northern Trust 12th March 2019

Western Trust 12th March 2019

Southern Trust 12th March 2019

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CONTENTS

Definitions for Policy Document

1.0 Introduction

2.0 Clinical Coding Policy Statement

3.0 Staff

4.0 Training

5.0 Standards

6.0 Procedures

7.0 Communication

8.0 Validation & Audit

9.0 Security & Confidentiality

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Definitions for Policy Document

Unless stated otherwise these definitions are also available on the Regional HSC

Data Dictionary on the Information standards and Data Quality SharePoint site:

https://hscb.sharepoint.hscni.net/sites/pmsi/isdq/SitePages/DataDictionary.aspx

Clinical Coder

Health informatics professional that undertakes the translation of the medical terminology in a patient’s medical record into classification codes. Clinical coders use their skills, knowledge and experience to assign clinical codes accurately and consistently in accordance with the classification and national and regional clinical coding standards. They provide classification expertise to inform coder/clinician dialogue. Regional Clinical Coding Forum

Clinical Coding

Clinical Coding is the translation of medical and surgical terminology that describes a patient’s complaint, problem, treatment or other reasons for seeking medical attention into clinical codes that can then be easily tabulated, aggregated and sorted for statistical analysis in an efficient, timely and meaningful manner. National Clinical Coding Standards ICD-10 5th Edition Reference Book (2016)

Consultant Episode

The time a patient spends in the continuous care of one consultant or, in the case of shared care, in the care of two or more consultants. Where care is provided by two or more consultants within the same episode, one consultant will take overriding responsibility for the patient and only one consultant episode is recorded. Additional consultants participating in the care of patient are defined as Shared Care (Joint) Consultants. A consultant episode includes those episodes for which a General Medical Practitioner is acting as a consultant. A patient going on home leave does not interrupt the consultant episode. A patient may not have concurrent consultant inpatient episodes but can have consultant out-patient episodes overlapping with a consultant episode. Any time spent as a lodged patient before being admitted to a ward is included in the first consultant episode. A consultant transfer occurs when the responsibility for a patient

https://hscb.sharepoint.hscni.net/sites/pmsi/isdq/SitePages/DataDictionary.aspx

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transfers from one consultant (or GP acting as a consultant) to another within a hospital spell. In this case one consultant episode will end and another one will begin. Activity Definitions Working Group / Acute Hospital Information Group

HRG Developed by the National Casemix Office, Health Resource Groups (HRGs) are standard groupings of clinical similar treatments which use common levels of healthcare resource. Healthcare Resource Groups offer organisations the ability to understand their activity in terms of the types of patients they care for and the treatments they undertake. They enable comparison of activity within and between different organisations and provide an opportunity to benchmark treatments and services to support trend analysis over time. HRGs are currently used as a means of determining fair and equitable reimbursement for care services delivered by Health Care Providers. Their use as consistent ‘units of currency’ supports standardised healthcare commissioning across the NHS. They improve the flow of finances within – and sometimes beyond – the NHS. NHS Data Model and Dictionary, NHS Digital

ICD-10 ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) It is a product from the family of international classifications produced and owned by the World Health Organisation (WHO). This diagnostic classification contains clinical codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. National Clinical Coding Standards ICD-10 5th Edition Reference Book (2016)

OPCS-4 OPCS Classification of Interventions and Procedures is a procedural classification for the coding of operations, procedures and interventions performed as part of NHS hospital activity Ownership and editorial rights belong to the Health and Social Care Information Centre National Clinical Coding Standards OPCS-4

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Classification A classification of diseases/procedures may be defined as a system of categories to which morbid entities/procedures are assigned according to established criteria. There are many possible axes of classification and the one selected will depend upon the use to be made of the statistics compiled. ICD-10 International Statistical Classification of Diseases and Related Health Problems

Medical Record

A medical record is a patient’s health record. A health record is any record of information relating to someone's physical or mental health that has been made by (or on behalf of) a health professional. This could be anything from the notes made by a GP in your local surgery to results of an MRI scan or X-rays.

Health records are extremely personal and sensitive. They can be held electronically or as paper files, and are kept by a range of different health professionals both in the NHS and the private sector.

Data Protection Act 1998

Source Document

The source document is the relevant recorded information that a clinical coder uses to extract the diagnoses and procedures that relates to the finished consultant episode they are clinical coding. The recommended source document for clinical coding is the patient’s medical record as stated in the definition for medical record. The structure and contents of the source document may differ between hospital sites. Regional Clinical Coding Forum

Information Governance

Information governance describes the approach within which accountability, standards, policies and procedures are developed and implemented, to ensure that all information created, obtained or received by the HSC organisation is held and used appropriately. Information Governance, Health & Social Care Board

Hospital Spell/ Provider Spell

A Hospital Spell is the total continuous stay of a patient using a bed on premises controlled by a health care provider during which medical care is the responsibility of one or more consultants. In some circumstances a patient may take home leave, which does not interrupt the hospital spell or consultant episode. Each admission as part of a series of regular day/night admissions generates a separate hospital spell and consultant episode. An admission is the start of the patient's hospital spell and the first consultant episodes within the spell. If the patient is on a hospital site the admission will also start the first hospital stay and, unless

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the patient has to spend time as a lodged patient, the admission will also start the first ward stay within that hospital spell. A discharge will be the end of the last consultant episode and ward stay within that hospital spell. If there is any time spent as a lodged patient before transfer to a ward this is included in the hospital spell. Activity Definitions Working Group / Acute Hospital Information Group

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1.0 Introduction

Clinical Coding is the translation of medical terminology that describes a patient’s

complaint, problem, treatment or other reasons for seeking medical attention into

codes that can then be easily tabulated, aggregated and sorted for statistical

analysis in an efficient and meaningful manner.

Accurate clinical record keeping underpins accurate clinical coding. Clinical coders

rely on medical staff to accurately document the main condition and other conditions

relevant to an episode of care. Consultant Episodes (CEs) with missing, inconsistent

or incorrectly recorded main conditions will be highlighted for investigation and

clarification to the relevant clinician by the Trust’s trained clinical coders.

This policy sets out the high level regional requirements for clinical coding to ensure

compliance with standards, accuracy and consistency of information produced

during the clinical coding process.

A Trust specific Clinical Coding Policy must be in place to support this

regional policy.

Throughout this document there is guidance as to what should be

included in each Trust specific policy. This will be shown in italics.

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1.1 Purpose of Clinical Coding

Treatment Effectiveness

Clinical

Statistical

Commissioning

Clinical Indicators

Health trends

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2.0 Clinical Coding Policy Statement

The Clinical Coding service aims to provide accurate, complete, timely coded clinical

information. The codes are used to support many functions across HSC and this

includes:

Clinically – Clinical Governance, Clinical Audit and Outcome and

Effectiveness of Patient's Care and Treatment

Statistically – Cost Analysis, Commissioning, Aetiology Studies, Health

Trends, Epidemiology Studies, Clinical Indicators and Case mix Planning

To fulfil these aims the Regional Clinical Coding Team will:

Maintain their Clinical Coding training and accreditation status

Develop and deliver a regional training programme

Promote and mentor for the UK Clinical Coding Qualification

Collaborate with clinicians to create effective guidance and training

Develop regional clinical coding standards to meet the particular needs and

legislative requirements of NI HSC including regionally standardised coding

standards for new models of clinical care as they develop.

Encourage shared working between trusts for example through workshops,

and the Regional Clinical Coding Forum

Monitor the levels of coding completion, accuracy and quality across the

region

Provide standardised and consistent resolutions to queries through the

regional helpdesk

Work collaboratively with the UK and Republic of Ireland to garner and

provide knowledge on best practice

Represent NI on UK Clinical Coding Committees/Groups.

Establish and carry out an external audit programme in collaboration with

Trusts

Represent NI on Terminology related meetings, providing a link and expertise

with Clinical Coding

Promote the profile of the clinical coding profession

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Ensuring that there is continual and maintained improvement of clinical coded

information and keep aware of clinical coding developments

Will coordinate an action plans through the Strategic Clinical Coding Group

and aligned the Information Standards work plan to ensure NI coding practice

evolves to respond to the needs of new programme of work such as

Encompass.

To fulfil these aims Trusts will:

Maintain required depth and quality of coding and outline steps to deliver

same in local policy

Work with the regional team to ensure staff attend and participate fully in all

training provided

Support the regional training programme through regular in-house training

and mentorship

Data quality issues affecting coding quality to be escalated via appropriate

internal procedures for resolution.

Ensure procedure decisions made with individual clinicians are fully

described, agreed and signed by the relevant personnel.

Ensure procedures do not contravene regional and national standards or

classification coding rules and conventions.

Ensure effective communication arrangements for the dissemination of

information regarding coding, resolutions to queries and changes in coding

practice to all coding staff and users of the information

Inform the Regional Team if errors found in a trust process that equates to the

incorrect assignment of code(s) so that accurate regional information can be

provided

Undertake validation/internal audit of clinically coded data and processes

Fully participate in external audit and action recommendations identified

Ensure there is adherence to local and national policies/legislation for

confidentiality and security during the coding process

Promote the role of the Clinical Coding Department both within the Trust and

external to this

Participate and support action plans developed by the Regional Team

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All clinical coding staff are responsible for participating in all relevant training

and development opportunities abiding by the code of conduct, working to the

agreed local, regional and national standards/procedures, reporting any issues

in relation to information recorded, ambiguities in training materials and lack

of guidance in relation to diagnoses and procedures, collaborating with

clinical staff and acting in a professional manner.

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3.0 Staff

The Regional Clinical Coding Team is part of the Information Standards and Clinical

Coding Team within the eHealth Directorate, HSCB. The Senior Information

Manager is responsible for the Information Standards and Clinical Coding Service.

The Regional Clinical Coding Co-ordinator leads the Clinical Coding team which

includes: Clinical Coding Auditor; Clinical Coding Trainer and Clinical Coding

Advisor.

Trusts are responsible for providing regular updates to the Strategic Clinical Coding

Group regarding number of staff and vacancies as part of the Key Performance

Indicators.

Further to this the Trust Clinical Coding Policy must show the organisation of the of

the Trust coding department. However additional information (see below) may be

held in a separate document.

number of staff and whole time equivalents (WTE)

Departmental structure – management structure, centrally based or devolved,

divided into directorates, grading of staff, job descriptions, workload

estimates, time scales etc.

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4.0 Training

All the staff within the regional clinical coding team have attained their National UK

Clinical Coding Qualification. The trainers and auditors within the team are

accredited and this is reviewed on an annual basis – attending forums in England,

submitting evidence of the courses delivered or audits carried out and taking part in

online forums from the HSCIC.

Clinical coding training is led by the two accredited trainers. The training delivered

across the NHS uses the same source materials so giving confidence that the quality

of coded clinical data is consistent across different NHS trusts. However more

specialised / regional specific courses are both developed and delivered by the

trainers. The trainers also provide support for the development of Trust trainees at

agreed points following the completion of the National Clinical Coding Standards

Course. There is further information available in the Regional Clinical Coding

Training Programme and in the Training Procedures and Forms which are available

on the Clinical Coding SharePoint site.

The trainers attend the annual National Clinical Coding Trainer Forum giving them

opportunity to input in to how clinical coding training is developed and implemented

across the UK and to bring forward suggestions from Northern Ireland.

Both trainers provide quality assurance for NHS Digital in relation to new

international/national classifications to be implemented and for the training material

and reference book that will accompany them.

Both trainers act as invigilators for the National UK Clinical Coding Qualification.

The Regional Clinical Coding Co-ordinator is the NI representative on the UK

Governance Board for the examination, they are responsible for:

Quality assuring the examination

Dealing with any complaints from candidates or invigilators

Clinical Coding ‘eLearning’ for non-coders. This is available to previously those who

have previously trained in clinical coding and training has lapsed but they are

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responsible for assisting with the coding process within their trust. For example

some Clinical Coding Managers, those who work in other Trust departments but

carry out overtime for clinical coding. To receive a copy of current ICD and OPCS

books the person must meet the criteria as identified in the Guidance for this course

(available on SharePoint). This also details the process in relation to completion of

the assessment.

The Trust Clinical Coding Policy must explain in detail or direct staff to where they

can locate:

Induction policies & procedures

Mandatory training requirements

Details regarding their assigned mentor and the period for which this will apply

Local/trust specific training

4.1 Training Records

The Regional Clinical Coding Team holds a list of regional courses/workshop dates

for all clinical coding staff.

Clinical Coding Managers/Supervisors are responsible for holding a record of their

own staff training records. The Trust Clinical Coding Policy should provide further

detail on this.

4.2 Appraisal & Development

All Trusts have appraisal process in place which should be explained within the Trust

specific policy.

All staff are responsible for maintaining their own personal

continuing development file with certificates and any other relevant

documentation.

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5.0 Standards

5.1 Performance

The key standard against which Trusts will be monitored is to have all acute activity

clinically coded within 3 months of discharge and to have that coding as deep and

accurate as possible. The Regional Team produce a monthly report which monitors

against this and other standards. The Clinical Coding Performance Monitoring

Definitions Document provides details of what the report contains including

standards monitored and exclusions.

5.2 Accuracy

The Regional Clinical Coding Team are responsible for liaising with appropriate

groups/individuals to develop and create regional clinical coding standards. These

standards are to meet the service needs particular to HSC in Northern Ireland. They

further ensure clinical coding is legislatively correct in relation to Northern Ireland

laws.

Trusts must fully implement all regional standards and current versions are available

on SharePoint.

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6.0 Clinical coding procedures

The Trust specific Clinical Coding Policy must list all procedures in relation to

inpatient and outpatient (as appropriate) clinical coding undertaken in the Trust.

These should either be included with the policy or an indication as to the location of

the procedures provided. There is a responsibility on Clinical Coding Departments to

ensure that these procedures are kept up to date and that staff are made aware of

new/changed procedures.

It is recommended that there is use of the medical record – can range from a full set

of case notes to an electronic health record when coding, as this source document

contains all the relevant information about the patient’s hospital stay. This is in line

with current NHS Digital recommendations. However it is recognised that it may not

always be possible to use the full case notes therefore the Trust Clinical Coding

Policy and associated documents must explain other processes used i.e. the source

document(s) used for each specialty/site within their Trust.

When developing procedures the following points should be considered:

Information documented on the proforma by the clinical staff on the patient’s

discharge

Clinical records collected from wards

Information regarding the patient’s diagnosis and treatment is extracted from

the proforma and clinical records by clinical coding staff

Translation of the information into the appropriate coded format and entered

onto the NHS hospital computer system, such as PAS, and the time scale for

this to happen

Details of the source document for coding purposes what this includes for

example Clinical records include discharge summaries, clinical notes, test

results, operation sheets, GP letters, the electronic systems

If the Trust is using proformas as the source document, stipulate that

information regarding the primary and secondary diagnoses/procedures

should be clearly documented on the form by the clinical staff, on the patient’s

discharge from hospital

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Point of coding, to include details of when the coding process is normally

instigated for example day of discharge, week after discharge following typing

of discharge summaries.

Coding aides, to include: details of computer systems or encoders used in the

coding process at the Trust such as Medicode, System C etc.

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7.0 Communications in clinical coding

All Clinical Coding information such as new/revised standards, dates for meetings,

workshops, training and audit schedules will be shared with Clinical Coding Forum

members via email and/or published on the Clinical Coding SharePoint site.

Trust Clinical Coding Policies should include details of arrangements in place for the

receipt and dissemination of relevant documentation (including that received from

the Regional Service such as query resolutions identified in 7.1) relating to clinical

coding across the department to endorse consistency and accuracy of coded

information.

Trust policies should reference guidelines for liaising with clinicians, other relevant

colleagues. There should also be a process to inform the Regional Clinical Coding

Team if errors found in a trust process that equates to the incorrect assignment of

code(s) so that accurate regional information can be provided.

7.1 Clinical Coding Helpdesk

The Regional Clinical Coding Helpdesk provides standardised clinical coding advice

to clinical coding, information and HRG queries sent from Trust clinical coding and

information departments, HSCB/Department of Health information departments,

HSCB Finance Department and third parties.

7.1.1 Trust Clinical Coding Queries

Trusts should have in place an appropriate query mechanism for internal and

external queries relating to clinical coding. The mechanism should include the

following steps:

Reference to all current clinical coding material such as the National Clinical

Coding Standards ICD and OPCS, Coding Clinic Collection and NHS

Information Authority clinical coding guidelines.

Liaise with appropriate clinician on applicable ICD and OPCS codes. Always

ensure that the advice given does not contravene the rules and conventions

of the classifications or national standards.

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Referring to senior level coding staff to determine whether the query can be

resolved internally.

Trust Clinical Coding Managers/Supervisors must refer queries using the form which

is available on the Clinical Coding SharePoint site. Completed forms are then sent

via email to the Regional Clinical Coding Advisor and copy to

[email protected] . The requestor should provide anonymised information.

The Regional Team will carry out wide ranging research including discussions with

Trust staff (clinicians / nurses / coding) to establish a consensus of opinion for

regional standards and collaboration with colleagues nationally and internationally.

Query resolutions are returned to the query originator. They are then added to the

ACC bulletin which is uploaded to SharePoint approximately every 8-12 weeks.

Managers/supervisors are advised when a new ACC has been uploaded to

SharePoint. These Trust representatives are then responsible for disseminating

locally agreed resolutions. As stated above Trusts should have a procedure which

documents the approach taken for communicating all information received including

resolutions.

7.1.2 Queries from other sources

There is a non-coding query form (available on SharePoint site) for queries from

other sources and this must be sent to Senior Information Manager (Information

Standards & Clinical Coding) and copy to [email protected] .They should

provide background information regarding the request and as much information as

possible to ensure a prompt resolution to the query. Query resolutions will be sent to

the requestor via email.

7.2 Meetings

The Regional Team are involved with a number of groups/committees both

regionally and nationally. This includes:

Strategic Information Group (SIG) and Information Standards Board (ISB) –

SIG provides strategic direction and oversight to the Health and Social Care

mailto:[email protected]

mailto:[email protected]

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(HSC) System regarding the use of information and ISB fulfils the operational

role.

Strategic Clinical Coding Group which is chaired by HSCB and has

representation from each Trust

Regional Clinical Coding Forum which is chaired by HSCB and has

representation from Trusts at a Clinical Coding management/supervisory level

Regional Clinical Coding Technical Assurance meetings are held regularly to

review draft resolutions

Regional Clinical Coding Coordinator is a member of the NCCQ Examination

Quality Assurance Board

Further to this the team attend Trust specific Coding meetings as required. The

Regional Team will represent Northern Ireland on the Information Representation

Services UK Strategy Board (IReS UKSB). This Board will provide strategic

leadership for a range of services including Classifications. The Regional Team also

provide representation to the UK Classification Technical Advisory Group which is an

advisory group to the UK IReS on the development and maintenance of the

classifications.

Trust specific policies should detail all relevant clinical coding meetings including

staff meetings.

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8.0 Validation & Audit of Clinical Coded Information

8.1 Validation

Trusts have in place their own arrangements for validation which must be detailed in

Trust specific policies.

The Regional Clinical Coding Team will coordinate testing to be carried out by each

Trust in relation to new versions of ICD or OPCS on systems such as PAS.

8.2 Audit

The Regional Clinical Coding Team are responsible for external audits carried out in

Trusts. Clinical coding audits are led by the two accredited clinical coding auditors.

Audits are used to identify clinical coding and other data source errors or issues as

well as evaluate the information processes involved in the collection of the data for

clinical coding purposes which ensures the highest possible standards of accuracy

and encourages best practice. The audit schedule is decided in conjunction with the

HSCB and Trusts.

The Regional Clinical Coding Audit Programme details the audit process and will be

shared with the organisation before the start of an audit.

Trust specific policies must point to the documents that detail their own audit

programme and methodology for internal audits. The Trust Policy or an associated

document will also explain audit roles & responsibilities.

8.2.1 Addressing errors/non-conformances

The Audit programme details the process for identifying and discussing clinical

coding discrepancies with Trusts during/after audit.

Trusts are responsible for addressing clinical coding discrepancies identified through

regional audits. Therefore Trust Clinical Coding Policies must include detail how

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Trust staff will be informed of findings and how discrepancies will be managed and

resolved.

8.3 Quality Assurance

Trusts must have in place quality assurance processes this may include:

Support/mentoring for staff new to a particular area

Quick fire tests to assess consistency and accuracy

Completion and sign of by coding staff acknowledgment of changes /

alterations in coding practice

Regular review of coding procedures to ensure reflective of the current

process

Documented agreements with medical staff to ensure they provide

appropriate and relevant information for the purpose of clinical coding

Use of unique identifier for all clinical coding staff

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9.0 Security and confidentiality

There should be effective security and confidentiality measures in place to ensure

patient confidentiality and the security of sensitive information. This includes staff

training and awareness in related areas.

Trust Clinical Coding Policies should indicate where staff can access any related

policies and guidance.

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