Targeted education for clinicians and clinical coding staff improves the accuracy of clinical coding: A quality improvement project.

The allocation of healthcare resources is reliant upon accurate information generated through clinical coding. Several factors contribute to coding inaccuracies, one of which is interpreting medical documentation. A lack of awareness among medical staff of the clinical coding process and the importance of detailed documentation exacerbates this problem.

Clinician-directed improvement in the accuracy of hospital clinical coding.

'Payment by results' (PbR) remuneration for healthcare services relies on the accurate conversion of diagnoses into Healthcare Resource Group (HRG) codes that are then reimbursed. Inconsistencies in documentation can result in inaccuracies in this process, with consequent implications for measuring activity, disease incidence and organisational performance. The aim of this study was to determine if clinician involvement increases accuracy in the coding of medical cases.

Impact of developing a multidisciplinary coded dataset standard on administrative data accuracy for septoplasty, septorhinoplasty and nasal trauma surgery.

Objective: This study aimed to develop a multidisciplinary coded dataset standard for nasal surgery and to assess its impact on data accuracy.

Method: An audit of 528 patients undergoing septal and/or inferior turbinate surgery, rhinoplasty and/or septorhinoplasty, and nasal fracture surgery was undertaken.

Results: A total of 200 septoplasties, 109 septorhinoplasties, 57 complex septorhinoplasties and 116 nasal fractures were analysed.

A stratified analysis of the perioperative outcome of 17623 patients undergoing major head and neck cancer surgery in England over 10 years: Towards an Informatics-based Outcomes Surveillance Framework.

Objectives: To perform a national analysis of the perioperative outcome of major head and neck cancer surgery to develop a stratification strategy and outcomes assessment framework using hospital administrative data.

Design: A Hospital Episode Statistics N = near-all analysis.

Settings: The English National Health Service.

Accuracy of clinician-clinical coder information handover following acute medical admissions: implication for using administrative datasets in clinical outcomes management.

Background: We evaluated the accuracy, limitations and potential sources of improvement in the clinical utility of the administrative dataset for acute medicine admissions.

Methods: Accuracy of clinical coding in 8888 patient discharges following an emergency medical hospital admission to a teaching hospital and a district hospital over 3 years was ascertained by a coding accuracy audit team in respect of the primary and secondary diagnoses, morbidities and financial variance.

Results: There was at least one change to the original coding in 4889 admissions (55%) and to the primary diagnosis of at least one finished consultant episodes of 1496 spells (16.

Role of reconstructive surgery in the management of head and neck cancer: a national outcomes analysis of 11,841 reconstructions.

Background: The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis.

Methods: An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units.

A Study of Clinical Coding Accuracy in Surgery: Implications for the Use of Administrative Big Data for Outcomes Management.

Background: Clinical coding is the translation of clinical activity into a coded language. Coded data drive hospital reimbursement and are used for audit and research, and benchmarking and outcomes management purposes.

Methods: We undertook a 2-center audit of coding accuracy across surgery.

A national analysis of the outcome of major head and neck cancer surgery: implications for surgeon-level data publication.

Objectives: To undertake a national outcomes analysis following major head and neck cancer surgery in order to identify risk factors for complications and in-hospital mortality, as well as areas whose closer examination and formal benchmarking in the context of local and national quality assurance audits may lead to improved results for this condition.

Design: An analysis using Hospital Episode Statistics data.

Settings: All units undertaking major head and neck cancer surgery in England.

Audit of accuracy of clinical coding in oral surgery.

We aimed to study the accuracy of clinical coding within oral surgery and to identify ways in which it can be improved. We undertook did a multidisciplinary audit of a sample of 646 day case patients who had had oral surgery procedures between 2011 and 2012. We compared the codes given with their case notes and amended any discrepancies.

An audit of the nature and impact of clinical coding subjectivity variability and error in otolaryngology.

Objectives: To audit the accuracy of clinical coding in otolaryngology, assess the effectiveness of previously implemented interventions, and determine ways in which it can be further improved.

Design: Prospective clinician-auditor multidisciplinary audit of clinical coding accuracy.

Participants: Elective and emergency ENT admissions and day-case activity.

Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit.

Clinical coding is the translation of documented clinical activities during an admission to a codified language. Healthcare Resource Groupings (HRGs) are derived from coding data and are used to calculate payment to hospitals in England, Wales and Scotland and to conduct national audit and benchmarking exercises. Coding is an error-prone process and an understanding of its accuracy within neurosurgery is critical for financial, organizational and clinical governance purposes.