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Audit of the accuracy and remunerative implications of clinical coding in Elective Plastic Surgery
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  • Andreas Georgiou,
  • Julia Ruston,
  • Shameem Haque,
  • Alex Woollard
Andreas Georgiou
Royal Free London NHS Foundation Trust
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Julia Ruston
Royal Free London NHS Foundation Trust
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Shameem Haque
Royal Free London NHS Foundation Trust
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Alex Woollard
Royal Free London NHS Foundation Trust
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Abstract

Introduction Accurate coding is essential to ensure remuneration for clinical procedures. However, coders are non-clinical and use operative and discharge notes to infer what they think to be appropriate codes. As plastic surgery encompasses a huge variety of procedures the codes used may not reflect the procedures performed. Method Electronic records from July/August 2019 were consulted to identify commonly performed procedures on elective lists which were then reviewed retrospectively by a coding auditor and a clinician. Procedures chosen to reflect a range of plastic surgery: 1) hands, 2) breast, 3) general plastics. The changes to the clinical codes (Procedural and Diagnostic) and HRG tariff implications were analysed. The audit loop was completed in July 2020 after the introduction of clinical coding improvement strategies. Results 65 relevant cases were included. Changes were made in 31 cases (24 OPCS-4 code changes and 7 ICD-10 code changes). Significant remunerative implications for the department were noted (average £209 per patient). Conclusion This study demonstrated a clear need for collaboration between clinicians and coders. Increased surgeon awareness of clinical coding and clear documentation is essential. We have presented strategies of improving coding that is part of as part of a continued quality improvement programme.

Peer review status:POSTED

15 Sep 2020Submitted to Journal of Evaluation in Clinical Practice
18 Sep 2020Assigned to Editor
18 Sep 2020Submission Checks Completed