What is Clinical Coding?
NHS Digital:
“The translation of medical terminology that describes a patient’s complaint, problem, diagnosis, treatment or other reason for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted for statistical analysis in an efficient and meaningful manner.”
Give 5 uses of clinical coded data.
- Health trends
- Cost analysis
- Outcome measurement
- Epidemiological studies
- Clinical governance
Give the 4 steps to the clinical coding process.
- Admission and discharge details completed for patient on APAS.
- Clinical coding administrators collect the notes from wards daily.
- Clinical coders go through notes and assign codes. HRG automatically generated from the codes.
- Coded information used to get SLAM data which is submitted to commissioners for payment.
What are the two main coding classifications used in the NHS?
- ICD -10: international, WHO publication, used to capture diagnostic clinical data.
- OPCS-4: UK specific, used to capture surgical interventions and procedures.
What is HRG 4+?
It is the grouper that is automatically generated from the codes. E.g. DZ 11 R
D - chapter
Z - subchapter
11 - number
R - split
It incorporates the level of comorbidity and complexity.
How are comorbidities coded?
The coder may only use the comorbidities entered in the medical record for the current admission i.e. no look back allowed.
