Surgeon Involvement in Clinical Coding: A Leap Towards Accurate Data and Better Remuneration

The world of healthcare is increasingly digitised, making the accuracy of clinical coding crucial. Clinical coders depend on precise data regarding diagnoses and procedures to generate an accurate representation of clinical activities. This process ensures that appropriate remuneration is received for the services provided. However, it seems that there’s room for improvement in this process – particularly in the field of shoulder and elbow surgery.

The Potential of Surgeon Involvement in Clinical Coding

According to a study conducted by Steven Kyriacou et al., which was published in the Journal of Shoulder and Elbow Surgery, surgeon input can greatly improve the quality of clinical coding. This involvement not only enhances data quality but also increases the remuneration received for operative interventions performed. This study shows how the collaboration between clinical coders and the surgical team can potentially improve the accuracy of this process.

How the Study was Conducted

Between November 2017 and November 2019, 19 meetings took place between the Senior Clinical Fellow of a tertiary Shoulder & Elbow Unit and the coding validation lead of their Trust. During these meetings, the Clinical Fellow assessed the operative note of cases where uncertainty existed as to the most suitable clinical codes to apply. The Clinical Fellow then selected the codes which most accurately represented the operative intervention performed.

What the Results Showed

Over the 24-month period, the clinical coding was reviewed in 153 cases. The result? Clinical coding was amended in a whopping 67% of these cases. Notably, this increased accuracy in coding also led to an additional income generation. A total of £115,160 additional income was generated as a result of this process.

Specifically, it was found that only 6 out of 28 cases initially coded as arthroscopic sub-acromial decompressions were correctly coded as such. This illustrates the extent to which current coding practices may be misrepresenting the actual interventions performed.

The Takeaway: Surgeon Collaboration is Key

In essence, this study by Kyriacou et al. highlights the vital role that surgeons can play in the process of clinical coding. By involving surgeons directly, there was a clear improvement in both the accuracy of the data and the corresponding remuneration.

These findings make it clear that collaboration between clinicians and clinical coders should be encouraged. This type of interdisciplinary cooperation can significantly enhance the quality of clinical coding, ensuring accurate representation of procedures and maximising the revenue earned for services provided.

It’s an important lesson for all of us in the healthcare industry – collaboration can truly be the key to better outcomes.

Kyriacou S, Butt D, Rudge W, Higgs D, Falworth M, Majed A. Surgeon involvement in clinical coding to improve data accuracy and remuneration in a shoulder and elbow unit. JSES Int. 2023;5(2):175-181. doi:10.1177/1758573221991530

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