What is Clinical Coding?
- Sarah Scriven
- Mar 14, 2022
- 9 min read
Thank you to all those who attended the joint FEDIP webinar, this month presented by Lauren Saxton from IHRIM.
If you missed it, not to worry, please have a read through of the transcript and all the information presented below. If you have any questions, please do get in touch with Lauren or her colleagues at IHRIM for further information on clinical coding.
An Introduction to Clinical Coding
The session is aimed at those wanting to learn more about Clinical Coding and colleagues who work with data that is derived from Clinical coding, it is also aimed at Clinicians whose documentation impacts code assignment and also Coding colleagues who may be looking for some engagement ideas.
This session was created by Lauren Saxton, Director of Comms for IHRIM. Lauren also works full time for the NHS at Rotherham NHS Foundation Trust as a Clinical Information Assurance Lead. Lauren is a qualified Clinical Coder and Coding Team Leader.
Lauren has worked for the NHS for 15 years - 12 years of Clinical Coding experience and 3 years of Clerical/Receptionist experience prior to joining Coding.
What is Clinical Coding?
Clinical Coding is the translation of medical terminology about why a patient is in a hospital into a coded format that is nationally and internationally recognised.
Coders go through a rigorous training programme that takes around 2 years, in which they’re taught national and local standards as well as anatomy and physiology.
Coding Departments are internally and externally audited, and Coders have to work independently towards the National Clinical Coding Qualification.
Below is an overview of the coding process. It all begins for the Coding Department once a patient has been discharged from the hospital.
The full medical record will then be accessed by a Clinical Coder and the relevant information would be extracted. This includes the main condition treated or investigated, any secondary diagnosis, comorbidities and any relevant procedures or interventions.
The medical documentation is closely analysed and then translated into a coded format taking into account Clinical Coding Standards and any local policies or guidance that the Coding Department may have in place.
After the information has been coded the data is then uploaded to the data warehouse known as SUS.
SUS stands for the Secondary Uses Service and is a collection of health care data required by hospitals and used for planning health care, supporting payments, commissioning policy development and research.
How It Is Done
We read the entire record, i.e. EMR and also the physical paper case notes where they’re still used and translate the medical terminology into codes.
We use hospital systems such as Meditech, Infoflex and ICE. We also use procedure notes and theatre information – the entire op note, not just the op title or proposed procedure, and we use any accompanying histology reports as well.
We use pretty much everything from a patient's inpatient stay.
On average Coders read between 720 and 1,440 pages of Clinical Documentation per day which is equivalent to three to four novels!
The International Classification of Diseases.
I’m not sure if any of you have ever visited Coding Departments in your Trust, but if you have you have, then you have probably seen the books that Coders use to enable them to translate medical terminology into a coded format. One set of these is the ICD – International Classification of Diseases.
ICD is made up of 3 volumes. Coders follow a four-step coding process, using an alphabetical index and a tabular list to ensure that they assign the correct code. There is also an instruction manual as well as a supporting Coding Standards/Reference book.
ICD ensures that coded data is comparable locally, regionally, nationally and internationally.
Some fun facts about ICD –
ICD has been translated into 43 languages.
ICD is used in more than 100 countries to report mortality data. ICD is the global health information standard for mortality and morbidity statistics.
70% of the world's health expenditures are allocated using ICD for reimbursement and resource allocation.
OPCS is used for the classification of interventions and procedures. OPCS ensures that coded data is comparable locally, regionally and nationally.
OPCS is made up of 2 volumes. Coders follow a four-step coding process, using an alphabetical index and a tabular list to ensure that they assign the correct code. There is also a supporting Coding Standards/Reference book.
Clinical Coding Standards
Coders have to adhere to Clinical Coding Standards and follow classification index trails using ICD and OPCS to assign codes, we are unable to just guess or pick a code to assign.
Code assignment is entirely dependent upon documentation in the medical record for an episode of care, and this is the current admission only, we are unable to look back at previous documentation for code assignment purposes.
Uses of Clinical Coding
The data derived from clinical coding is used for many different purposes.
Coding is used for financial reimbursement and is used to ensure Trusts are paid accurately for the care they deliver. Coded data is used to calculate block contracts that some Services may have in place.
Coded data is also used for clinical governance, clinical audit, measuring treatment effectiveness. If Departments are running an audit and want to find out how for example how many patients had a hysterectomy in the last 10 years, the coding department would provide the codes that will then enable the information team need to run a report.
Coded data is also used for statistical purposes, like aetiology and epidemiology.
It’s used for outcome measurement and measuring treatment effectiveness, and for casemix planning and commissioning – coded data is the way we as a Trust tell the NHS what we’re doing and the complexity of the patients we treat.
Getting More Engagement For Clinical Coders
Clinical Coding is becoming a much more known role in the NHS but it hasn’t always been that way. A lot of Coders will tell you that they ‘fell into coding’ after already working in the NHS, usually in a clerical role, and only hearing about the role when vacancies were advertised. This certainly was the case for me. I never had the ambition to become a Coder or work in the Health Informatics field.
One of the biggest challenges with coding is documentation as code assignment is so heavily reliant upon the documentation that is present.
Here are a few engagement tips that I wanted to share with you all for any Coders / Clinicians on the call to hopefully take away and look to implement something similar at your Trust. These opportunities will allow you to showcase the Coding role and impacts that documentation may have on code assignment to hopefully optimise and increase the richness of your data.
At my Trust we established that a lot of Junior Doctors and Nurses had access to Twitter so we contacted our Trust Communications team to set up a Coding Department Twitter page to allow us to share top tips regarding documentation but also to showcase the Department's achievements and do some profile-raising of the profession.
We are currently running a coding champion programme alongside some Junior Doctors who have expressed an interest in Clinical Coding. The idea is that the Junior Doctors who are part of the programme will take their newfound knowledge back to their Specialities and spread the word.
Assigning experienced Coders as Service Engagement Leads whose responsibility it is to work with that particular Service.
Some other ideas are - You could also set up Clinical Coding stalls in communal areas, hold lunchtime drop-in sessions once per month for any coding related Clinicians may have, Having a regular slot on any Trust Communications/newsletters, Optimise Trust Intranet Sites with a dedicated Clinical Coding page, Creating ID sized cards with the documentation terms which Coders can and can’t use and distributing these at Junior Doctors Inductions
How Can You Help Clinical Coders?
I’m not sure if we have any Clinicians on the call but if so, this slide is for you guys! What do coders need to do their job? We need clear, accurate and full documentation. Coders are not medically trained and are forbidden by national standards to interpret clinical information such as early warning scores, blood results, medication lists etc. and rely on clear documentation from clinicians to determine patient diagnoses and support code assignment.
A big issue has always been legible documentation – but some of this is a lot easier now with EPR.
Our job is to translate what is written – we need you to state that the patient has hypercholesterolaemia rather than just writing that the patient is on a statin.
We are not allowed to interpret results - if you write that the patient has lost litres of blood after labour, we know they’ve probably had a post-partum haemorrhage.. But if you don’t document that, we can’t code it.
We also aren’t allowed to assume links between conditions – they have to be documented in the medical record. So if a patient has a bleed and anaemia, we need the link between them to be explicit in order for us to code anaemia due to haemorrhage rather than just the anaemia on its own.
The same thing goes for procedures. When you’re writing the op note, we need you to document the whole procedure performed – when you do an adhesiolysis, we need to know exactly which organs have been freed. If you don’t document it, we can’t code it and we could lose out on the correct reimbursement for that part of the procedure and we will submit inaccurate data about the care we deliver.
Routes into Clinical Coding
A novice NHS clinical coder needs to agree to a 2-3 year development plan with their employer to complete the necessary training, acquire the skills, knowledge and practical work experience to become competent in clinical coding and be ready to sit the examinations to achieve accreditation.
The National Clinical Coding Qualification (NCCQ) is the nationally recognised quality standard that provides independent assurance of the clinical coding practitioners’ competency in the use of the clinical classifications and knowledge of how to apply their associated rules, conventions and national clinical coding standards.
The NCCQ
The National Clinical Coding Qualification (UK) is the only nationally recognised qualification for clinical coders working in the NHS. Upon passing the examination a clinical coder is able to use the post-nominal letters ACC.
IHRIM is the awarding body for the NCCQ and to be able to take the NCCQ you must be a member of IHRIM.
The NCCQ is made up of two parts practical and theory.
The pass mark is 90% for practical and 60% for theory due to the role requirements of a Clinical Coder being heavily dependent on accurate code assignment.
The qualification also acts as evidence of compliance with the Data Security and Protection Toolkit (DSPT) and can help an organisation towards meeting those standards.
Attainment of the NCCQ is only one step in a coder's career and in order for their ACC status to maintain currency practitioners must also be able to demonstrate continuing professional development, i.e. it is mandatory to attend a Clinical Coding Refresher Course every 3 years.
An Introduction to IHRIM
IHRIM is the professional organisation for people working in health informatics, be it health records, patient services, clinical coding or information governance.
IHRIM is primarily an educational body and examinations at various levels are carried out.
These include Health Informatics Exams and the National Clinical Coding Qualification.
IHRIM is made up of 2x full time employed Office Admin staff and the rest of the team are all voluntary alongside their NHS roles.
Membership of the Institute means being part of an internationally recognised professional organisation
IHRIM’s collaboration with FEDIP (The Federation of Informatics Professionals) gives members the opportunity to be proactive with regard to legislative changes, developments and compliance within their organisation
IHRIM is the only professional organisation offering comprehensive qualifications for health records and health information professionals at all grades. An IHRIM qualification offers a competitive edge with employers, potential employers, colleagues and peers. IHRIM qualifications are recognised as the benchmark of professional excellence.
Free places & reduced rates for attendance at relevant conferences/masterclasses for IHRIM members
Access to the Privacy & Data Protection Journals: IHRIM members have FREE access to these journals in the members-only section of the IHRIM website
Members have access to additional areas of the IHRIM website (www.ihrim.co.uk) that are not accessible to non-members including the EXCLUSIVE ability to access ALL IHRIM past papers which are © IHRIM.
If you would like to become a member you can do this by visiting the IHRIM website and downloading an application form.
Information on how to become a member / membership fees are all available on our website.
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Thank you everyone for your time today, I hope you all have a good week.
A tremendous thank you to Lauren for her excellent presentation.
If you have any questions, please do reach out to Lauren using the above contact details. You might also be interested in downloading the FEDIP brochure to learn more about FEDIP registration through IHRIM.
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