Unleashing the Power of Collaboration: The Key to Improving Accuracy in Clinical Coding in Surgery

Hey, medical mavens! Let’s dive deep into another intriguing realm today: clinical coding in surgery, and how collaboration can enhance its accuracy. Sounds exciting? Let’s get going.

I recently stumbled upon a compelling study led by Nick A. Heywood and an amazing team of experts from the Northwest Research Collaborative. Their research was all about honing the precision of clinical coding within the surgical field, specifically in hospitals located in the Northwest of England.

What is Clinical Coding, again?

If you’re a newbie to this topic, let’s quickly recap. Clinical coding is the process by which healthcare encounters, like diseases, health conditions, and treatments, are translated into a classification code. It’s vital for facilitating payments, allocating health and research resources, and bolstering public health data and planning.

The method to their madness…

The researchers conducted a comprehensive review of clinical coding practices across seven hospital trusts. They selected 208 patients who were discharged between March and August 2013 after undergoing emergency general surgery.

A senior clinical coder and a clinician then performed a “blind” re-coding of these cases, comparing the results with the original coding outcome. The aim was to check the level of accuracy and identify where errors were happening.

So, what did they find?

Well, here’s the kicker. They found that a whopping 93.3% of all the cases had at least one coding error, with 4.3% having errors in both the primary diagnosis and primary procedure. Ouch, right?

In terms of specifics, they found errors in 30.8% of primary diagnoses and 21.9% of primary procedure codes. You might be thinking, “What’s the financial implication?” Well, after recalculating using updated clinical codes, they found no significant difference in median tariff, proving that coding errors might not affect the revenue directly, but they can potentially distort Hospital Episode Statistics data, impacting the allocation of healthcare resources and public health planning.

Why so many errors?

The most frequent culprits behind these errors were “coder error” and the “need for clinical interpretation of notes”. This highlights the need for better collaboration between clinicians and coding departments. After all, the more accurate the coding, the better the public health planning and allocation of resources can be!

The key takeaway…

This study truly underlines the importance of collaboration between surgeons and coding departments. As we progress towards a future where surgeon-specific outcomes become the norm, this collaboration will be instrumental in ensuring the robustness of the system.

In the end, improving clinical coding is not just about getting the numbers right; it’s about ensuring the best possible healthcare for all. As we say, collaboration is key!

Until next time, folks. Keep exploring, keep learning!

Sources:

Nick A. Heywood, Michael D. Gill, Natasha Charlwood, Rachel Brindle, Cliona C. Kirwan, Natalie Allen, Pete Charleston, Pete Coe, Jill Cunningham, Sarah Duff, Leslie Forrest, Claire Hall, Sarah Hassan, Ben Hornung, Moayad al Jarabah, Ann Jones, James Mbuvi, Tonia Mclaughlin, James Nicholson, John Overton, Adam Rees, Hema Sekhar, Jennifer Smith, Stella Smith, Nicky Sung, Nicholas Tarr, Rebecca Teasdale, Janet Wilkinson, Improving accuracy of clinical coding in surgery: collaboration is key, Journal of Surgical Research, Volume 204, Issue 2, 2016, Pages 490-495, ISSN 0022-4804, https://doi.org/10.1016/j.jss.2016.05.023.