Audit of accuracy of clinical coding in oral surgery

Naran, Sanjay; Hudovsky, A.; Antscherl, Jeremy; Howells, Sally; Nouraei, S.A.R.

doi:10.1016/j.bjoms.2014.01.026

Cited by 23 publications

(21 citation statements)

References 5 publications

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“…Some form of data entry error is likely present. Diagnostic and procedural coding errors have been well documented in other studies, and the same is likely true for hospital charge entries (28)(29)(30)(31)(32).…”

Section: Resultsmentioning

confidence: 75%

Cost analysis of adolescent idiopathic scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon

Raudenbush¹,

Gurd²,

Goodwin³

et al. 2017

J. Spine Surg.

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Section: Resultsmentioning

confidence: 75%

Cost analysis of adolescent idiopathic scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon

Raudenbush¹,

Gurd²,

Goodwin³

et al. 2017

J. Spine Surg.

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“…In Nouraei et al [13], their ENT coding audit led to at least one change of coding in 44% of cases, and to HRG changes in 16%, with an income variance of £109.46 per patient. In Naran et al [14], their audit led to at least one change of coding in 77% patients, and to HRG code changes in 54% patients, with an estimated £114 in lost revenue per patient. In Martinou et al [15], 32% of their breast and endocrine operations were incorrectly recorded with an estimated loss of £17,000 to the Trust over the 2-month study period.…”

Section: Comparison With Literaturementioning

confidence: 99%

“…Clinician factors include lack of awareness of coding issues and diagnostic uncertainty [12,14]. Clinicians have little training and minimal exposure to the complexities of coding.…”

Section: Understanding the Cause Of Coding Errorsmentioning

confidence: 99%

Clinical coding and data quality in oculoplastic procedures

Juniat

Athwal

Khandwala

2019

Eye

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Introduction Hospitals in England are reimbursed via national tariffs set out by NHS England. The tariffs payable to hospitals are determined by the activity coded for each patient's hospital visit. There are no national standards or publications within oculoplastics for coding accuracy. Our audit aimed to determine the accuracy of coding oculoplastic procedures carried out in theatres and to assess the financial implications of any discrepancies. Methods We carried out a prospective audit of consecutive oculoplastic procedures performed at one hospital site over a 6-week period. We subsequently created a coding proforma and performed a re-audit using the same methods. Results In the first cycle, clinical coding was 'correct' in 30.7% of cases, 'incomplete' for 12.9% and 'incorrect' for 56.5%. Of the 'incorrect' codes, 54.3% were coded as non-oculoplastic procedures (e.g. extraocular muscle surgery). We discussed our findings with the coding team in order to address the sources of error. We also created a 'tick box' coding proforma, for completion by surgeons. Our re-audit results showed an improvement of 'correct' coding to 85.7%. Conclusion Clinical coding is complex and vulnerable to inaccuracy. Our audit showed a high rate of coding error, which improved following collaboration with our coding team to address the sources of error and by creating a coding proforma to improve accuracy. Accurate clinical coding has financial implications for hospital trusts and consequently Clinical Commissioning Groups. In times of severe financial pressures, this could be a valuable tool, if rolled out over all specialities, to make much needed savings.

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“…Continuous assessment of clinical coding is required to find ways to improve its accuracy [28]. In Andrews et al [14], a study comparing the coding consistency among three professional SNOMED CT coding companies showed no significant agreement among the experts with 33% of agreement on the same concepts.…”

Section: Discussion and Related Workmentioning

confidence: 99%

Qualitative analysis of manual annotations of clinical text with SNOMED CT

et al. 2018

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SNOMED CT provides about 300,000 codes with fine-grained concept definitions to support interoperability of health data. Coding clinical texts with medical terminologies it is not a trivial task and is prone to disagreements between coders. We conducted a qualitative analysis to identify sources of disagreements on an annotation experiment which used a subset of SNOMED CT with some restrictions. A corpus of 20 English clinical text fragments from diverse origins and languages was annotated independently by two domain medically trained annotators following a specific annotation guideline. By following this guideline, the annotators had to assign sets of SNOMED CT codes to noun phrases, together with concept and term coverage ratings. Then, the annotations were manually examined against a reference standard to determine sources of disagreements. Five categories were identified. In our results, the most frequent cause of inter-annotator disagreement was related to human issues. In several cases disagreements revealed gaps in the annotation guidelines and lack of training of annotators. The reminder issues can be influenced by some SNOMED CT features.

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Audit of accuracy of clinical coding in oral surgery

Cited by 23 publications

References 5 publications

Cost analysis of adolescent idiopathic scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon

Cost analysis of adolescent idiopathic scoliosis surgery: early discharge decreases hospital costs much less than intraoperative variables under the control of the surgeon

Clinical coding and data quality in oculoplastic procedures

Qualitative analysis of manual annotations of clinical text with SNOMED CT

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