Clinical coder

Abstract: 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 We undertook a multidisciplinary audit of neurosurgical clinical coding accuracy Neurosurgeons trained in coding assessed the accuracy of 386 patient episodes Where clinicians felt a coding error was present, the case was discussed with an experienced clinical coder Concordance between the initial coder-only clinical coding and the final clinician-coder multidisciplinary coding was assessed At least one coding error occurred in 71/386 patients (184%) There were 36 diagnosis and 93 procedure errors and in 40 cases, the initial HRG changed (104%) Financially, this translated to pound111 revenue-loss per patient episode and projected to pound171,452 of annual loss to the department 85% of all coding errors were due to accumulation of coding changes that occurred only once in the whole data set Neurosurgical clinical coding is error-prone This is financially disadvantageous and with the coding data being the source of comparisons within and between departments, coding inaccuracies paint a distorted picture of departmental activity and subspecialism in audit and benchmarking Clinical engagement improves accuracy and is encouraged within a clinical governance framework

Abstract: Recently, researchers in Australia, America, England and Canada have conducted national surveys of clinical coders in their respective countries. In Australia in 2002, the National Centre for Classification in Health (NCCH) in collaboration with the Health Information Management Association of Australia and the Clinical Coders’ Society of Australia conducted the National Clinical Coder Workforce survey, a study of clinical coders and coding managers . In America in 2002, the American Health Information Management Association (AHIMA) commissioned an independent national workforce research study to the Centre for Health Workforce Studies (CHWS), State University of New York at Albany to provide a picture of health information management roles today and forecast through 2010 . In England in 2003, the National Health Service Information Authority (NHSIA) conducted a national clinical coder survey, along with a survey of coding managers, in a similar format to that completed by Australia . In Canada, in 2002, a study was conducted by the Canadian Health Record Association (CHRA) (currently known as the Canadian Health Information Management Association (CHIMA)) and Thiinc iMi, which provided information regarding the various roles health record professionals have in the healthcare sector, the qualifications of health record professionals and their salaries . While these surveys have been conducted independently, they have addressed similar issues in terms of coders' salaries, educational backgrounds, roles and responsibilities, resources, experience, and continuing education needs. While several papers/reports have been generated from the individual research at a national level, there has been no systematic comparison of the coder workforce at an international level to date. This paper will describe the findings of each of the national surveys, and seeks to identify similarities and differences in important aspects of the coder workforce at an international level.

Abstract: The Hospital In-Patient Enquiry and National Perinatal Reporting System (HIPE & NPRS) Unit of the Economic and Social Research Institute in Ireland requested a review of its coder training programs and data quality initiatives, primarily because of the decision to implement a major change in Ireland's morbidity classification in January 2005. In August 2004, a formative evaluation using qualitative methods was conducted to assess the Unit's programs and initiatives. A number of opportunities for building on the solid frameworks the Unit has implemented were identified. In this paper, we focus on the Unit's coder training programs. The Unit's data quality initiatives will be discussed in a subsequent paper (Bramley & Reid 2005).

Abstract: Collections of routine, or 'administrative', hospital data have many applications in health care and are now recognised as valuable sources of information. In recent decades, administrative data have been seen primarily as funding and billing tools to assist with the reimbursement of hospitals for services provided; this purpose remains the primary focus of the clinical coder workforce. More recently, hospital data have been recognised as valuable resources for a range of health system improvement processes beyond funding. The focus of this paper is to review and demonstrate the diverse uses of administrative data in health services research and quality improvement. By gaining an understanding of how the data are used, we can appreciate the importance of good quality data from the perspective of its multiple uses. This paper describes a sample of the studies conducted in Australia using administrative data in health care improvement.