Enhancing Accuracy in Surgical Coding: A Pioneering Approach

How often do you think about the precision of procedural coding in surgical discharge summaries? You might not realize it, but accurate coding is essential in the world of healthcare. This was the focus of a study conducted by Eirini Martinou, Genevieve Shouls, and Nadine Betambeau, who explored ways to improve the accuracy of operation coding in surgical discharge summaries. So, let’s dive into their findings and discuss why this matters.

Understanding the Importance of Accurate Coding

First off, why is procedural coding so crucial? These codes, especially the OPCS codes (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures), serve multiple purposes. Not only do they inform healthcare staff about the procedures performed on a patient, but they also dictate the tariff that allows the hospital to be reimbursed for the procedure. In essence, these codes translate into the financial sustenance of the healthcare institution.

However, within their own breast and endocrine surgery department, the researchers noticed an alarming trend – the OPCS coding on discharge summaries often contained errors. An initial measurement over two months revealed that 32% of operations had been incorrectly coded. The implications? Incorrect tariffs were being applied, leading to an estimated loss to the Trust of £17,000. Clearly, something needed to be done.

A Simple Yet Effective Solution

To address this issue, the research team collaborated with the clinical coding team and breast surgeons to develop a specific OPCS coding table. This table summarized all operations performed within their department. Once created, this table was disseminated among the team, particularly to junior doctors, who are often tasked with completing the discharge summaries.

The Results Are In

The outcome of this intervention? Quite impressive! A re-audit revealed that 100% of operations were accurately coded, clearly demonstrating the effectiveness of the coding table.

The Future of Accurate Surgical Coding

The study strongly advocates for the introduction of specifically designed coding tables across each surgical department. By ensuring accurate use of OPCS codes, the quality of surgical discharge summaries can be significantly improved. Plus, it ensures the correct reimbursement to the Trust, contributing to the financial health of the institution.

Accuracy in surgical coding is more than just getting numbers and letters right. It’s about effective communication, optimal patient care, and financial stability. And as this study shows, a simple tool like a coding table can make a world of difference!


Martinou E, Shouls G, Betambeau N. Improving the accuracy of operation coding in surgical discharge summaries. BMJ Qual Improv Rep. 2014 Oct 21;3(1):u202053.w1990. doi: 10.1136/bmjquality.u202053.w1990. PMID: 26734286; PMCID: PMC4645875.

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