Orthopaedic procedure coding. Does accuracy matter?

Abstract

Purpose: Coding clinical work should allow accurate and precise methods of assessing individual or department activity. The NHS financial reforms have increased correct diagnostic coding importance by introducing "payment by results" so that funding is directly linked to patient activity. The aim of this study is to assess the accuracy of procedure codes (OPCS 4.4), and its effect on Healthcare Resource Group tariff codes that directly affect revenue.

Design/methodology/approach: A total of ten procedures from ten consultants were randomly selected over one month. Each consultant coded his or her own procedures. From these codes, Healthcare Resource Group tariff codes were assigned to each patient. These were compared with procedure and Healthcare Resource Group tariff codes generated by coding department staff.

Findings: Of 100 procedures, four were un-coded by coding department staff. There was concordance in 35 per cent of cases. Coders only gave one code for each procedure, whereas 35 per cent of procedures coded by consultants were assigned multiple codes. This resulted in 27 per cent of cases generating a different Healthcare Resource Group tariff code. Of the cases, five resulted in a difference of pound 4,000 or more; however, the overall difference was a pound 3,367 revenue loss if coder's codes were used.

Research limitations/implications: Study numbers were limited to 100 with five cases showing excessive financial gain or loss significantly influencing the overall result.

Practical implications: Present procedure coding practice is inaccurate and results in Healthcare Resource Group tariff codes that do not accurately represent clinical activity and productivity. Under payment by results, this can result in a significant revenue loss and possibly ultimately future referrals. Therefore, coding practice needs to be improved as a matter of urgency. Arguably, this could be achieved by closer communication between coders and clinicians.

Originality/value: The paper identifies a flaw in the way clinical activity and productivity is assessed at present. This is fundamental to the process on which "payment by results" is based, and therefore must be addressed if trusts are to be financially successful.