Audit of the accuracy and remunerative implications of clinical coding
in Elective Plastic Surgery
Abstract
Introduction Accurate coding is essential to ensure remuneration for
clinical procedures. However, coders are non-clinical and use operative
and discharge notes to infer what they think to be appropriate codes. As
plastic surgery encompasses a huge variety of procedures the codes used
may not reflect the procedures performed. Method Electronic records from
July/August 2019 were consulted to identify commonly performed
procedures on elective lists which were then reviewed retrospectively by
a coding auditor and a clinician. Procedures chosen to reflect a range
of plastic surgery: 1) hands, 2) breast, 3) general plastics. The
changes to the clinical codes (Procedural and Diagnostic) and HRG tariff
implications were analysed. The audit loop was completed in July 2020
after the introduction of clinical coding improvement strategies.
Results 65 relevant cases were included. Changes were made in 31 cases
(24 OPCS-4 code changes and 7 ICD-10 code changes). Significant
remunerative implications for the department were noted (average £209
per patient). Conclusion This study demonstrated a clear need for
collaboration between clinicians and coders. Increased surgeon awareness
of clinical coding and clear documentation is essential. We have
presented strategies of improving coding that is part of as part of a
continued quality improvement programme.