EC TWINNING PROJECT Development of National Coding Standards within the Czech DRG System CZ2005/IB/SO/03

Development of National Coding Standards within the Czech DRG System SEMINAR Best Practice for Clinical Coding and Data Quality 29 AND 30 APRIL 2008 Nora Sheridan ACC Resident Twinning Adviser

Development of National Coding Standards within the Czech DRG System What is Clinical Coding? The translation of medical terminology into a coded format which is nationally and internationally recognised

Development of National Coding Standards within the Czech DRG System What do we need to code correctly? Documentation Source document Clinician records the patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention

Development of National Coding Standards within the Czech DRG System What do we need to code correctly? Standards Classifications Coders apply the rules and standards of the classifications

Development of National Coding Standards within the Czech DRG System Documentation Electronic Case notes Discharge summary Proforma

Development of National Coding Standards within the Czech DRG System Electronic Documentation Electronic Patient Record UK working towards full EPR/EHR Access given only to relevant people Clinical information available nationally

Development of National Coding Standards within the Czech DRG System Case Notes Most widely used source document Clinical information – diagnosis and procedure Laboratory and histology results Discharge summary or transfer letter Final clinical letter

Development of National Coding Standards within the Czech DRG System Discharge summary Good discharge summary can replace medical record Identifies primary diagnosis Contains details of relevant co morbidities Results from investigations included Procedures recorded

Development of National Coding Standards within the Czech DRG System Proforma Usually of poor quality May be used for interim coding if other records unavailable – e.g. record transferred with patient Creates more work for coders Review of full record needed when available

Development of National Coding Standards within the Czech DRG System Standards Classifications Primary Diagnosis Definition Co morbidities Policy and Procedure Documents Data Validation Re-imbursement - HRGs

Development of National Coding Standards within the Czech DRG System Classifications Mandatory for Central Returns/Hospital Episode Statistics (HES) Diagnosis ICD-10 Procedures OPCS 4

Development of National Coding Standards within the Czech DRG System ICD-10 International Statistical Classification of Diseases and Related Health Problems (Tenth Revision) Replaced ICD-9 in the UK in 1995/96 NHS Connecting for Health holds UK licence allowing codes to be used across the NHS Records all diagnosis relevant to patient episode, symptoms or reason for encounter with health service

Development of National Coding Standards within the Czech DRG System OPCS 4 Replaced OPCS 3 in 1987 NHS Classifications Service (NCS) of NHS Connecting for Health is responsible for the support, maintenance, licensing and development of the OPCS Classification of Interventions and Procedures (OPCS 4) – Crown copyright Records all procedures relevant to patient episode Also used for recording High Cost Drugs

Development of National Coding Standards within the Czech DRG System OPCS 4 Planned annual upgrade – annual review Improve quality of procedure data collected by NHS Flexible and up to date classification system Reflects current clinical activity performed in NHS Statistical and financial planning Review of activity by commissioners more accurately Better health planning Improved patient care Responds to users feedback and change requests Support government policy for PbR – HRGs

Development of National Coding Standards within the Czech DRG System OPCS 4 OPCS 4.3 implemented 1 April 2006 OPCS April 2007 OPCS 4 5 due 1 April 2009 – final approval from NHS Information Standards Board (advance notice DSCN )

Development of National Coding Standards within the Czech DRG System Clinical Terms Read Codes 4 byte Version 2 Clinical Terms (Version 3) must map to classifications for central returns SNOMED CT

Development of National Coding Standards within the Czech DRG System Primary Diagnosis Definition Main condition investigated or treated during relevant episode of health care after all investigation and testing Select main symptom abnormal findings or problem where no definitive diagnosis is made Health Service Guideline (HSG(96)23 20 th September 1996 Mandated for use from 1 April 1997

Development of National Coding Standards within the Czech DRG System Recording Co-morbidities Record all relevant to episode of care Any condition which affects management of patient Affects treatment of patient Changes length of stay NHS Classifications Service reviewing co-morbidities

Development of National Coding Standards within the Czech DRG System Policy and Procedure Document Sample document available from NHS Classifications Service website All coding departments should have one Structure of department Source documentation Query resolution National policy commitment Other policies or guidelines Skill requirements and training Step by step procedures for coding

Development of National Coding Standards within the Czech DRG System Data Validation Coding Supervisor or Manager Information Department HRGs – U code (ungroupable)

Development of National Coding Standards within the Czech DRG System Who should perform the Clinical Coding function? Staffing Clinicians Clinical Coders Recruitment Training Career Pathways Examinations

Development of National Coding Standards within the Czech DRG System Clinicians Doctors Nurses Pharmacists etc Medically trained Need training to apply rules and standards of classifications

Development of National Coding Standards within the Czech DRG System Clinical Coders Administration staff Not medically trained Biology qualification e g A level Terminology and A & P training Basic instruction manual Training by nurses/medical staff Need training to apply rules and standards of classifications

Development of National Coding Standards within the Czech DRG System Clinical Coders Office support Classification Instruction Manuals ICD-10 OPCS 4 Anatomy & Physiology Instruction Manual Medical Dictionary Drugs Reference Books BNF MIMS Internet access

Development of National Coding Standards within the Czech DRG System Recruitment Hospital staff Medical staff Medical records clerks Ward clerks Local newspapers Health Journals

Development of National Coding Standards within the Czech DRG System Training Clinical Coding Foundation Course – 18 days Further training at hospital Work audited at hospital Experience gained through practical application Mental Health Foundation Course – 3 days Clinical Coding Refresher Course – 4 days

Development of National Coding Standards within the Czech DRG System Training Workshops Circulatory & Vascular Workshop – 4 days Obstetrics Workshop – 3 days Orthopaedic Workshop – 4 days Anatomy & Oncology Workshop – 3 days Chemo/Radiotherapy Workshop – 2 days NCCQ Revision Workshop – 3 days

Development of National Coding Standards within the Czech DRG System Career Pathways Novice/Trainee Coder Experienced Coder Accredited Coder Coding Team Leader Coding Supervisor Coding Manager Coding Trainer Coding Auditor Clinical Coding Service Manager

Development of National Coding Standards within the Czech DRG System Coding Trainer Accredited Clinical Coder (ACC) Train the Trainer Assessment Day Certificate in Training Delivery Skills (Training Foundation) ICD10/OPCS-4 Training Module (NHS Classifications Service) Healthcare Information & Its Uses (Information Centre) HRG Foundation Course (Information Centre)

Development of National Coding Standards within the Czech DRG System Coding Auditor Accredited Clinical Coder Proven report writing skills Clinical Coding Audit Workshop – successful completion Code of Practice for clinical coding auditors

Development of National Coding Standards within the Czech DRG System Examinations Testing throughout training courses NCCQ (UK) – National Clinical Coding Qualification (UK) - Accreditation Only recognised coding qualification Awarding body – IHRIM (Institute of Health Record and Information Management) oversee exam NHS Connecting for Health draft exam to current standards

Development of National Coding Standards within the Czech DRG System Where should Clinical Coding be done? Structure Which Department Departmental Structure Flow of Work

Development of National Coding Standards within the Czech DRG System Which Department Medical Records Information Department Finance Department Specialty based Ward based

Development of National Coding Standards within the Czech DRG System Departmental structure Clinical coders (approx episodes each per year) Team Leader Coding Supervisor Coding Manager

Development of National Coding Standards within the Czech DRG System Flow of work Medical records to coding department Clinical coders visit wards Codes input onto system Available for other departments and external requirements