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Improving the accuracy of operation coding in surgical discharge summaries
Eirini Martinou1, Genevieve Shouls1, Nadine Betambeau1
1St George's Healthcare NHS Trust.
BMJ Quality Improvement Reports
|January 7, 2016
Summary
Accurate procedural coding in surgical discharge summaries is vital for correct hospital reimbursement. Implementing a specific OPCS coding table significantly improved coding accuracy from 32% to 100% in a breast and endocrine surgery department.
Area of Science:
- Health Services Research
- Surgical Operations
- Medical Coding
Background:
- Procedural coding in surgical discharge summaries is crucial for clinical communication and hospital reimbursement via OPCS (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures) codes.
- Inaccurate OPCS coding can lead to incorrect hospital tariffs and significant financial losses.
- The breast and endocrine surgery department identified frequent errors in their discharge summary coding.
Purpose of the Study:
- To assess the accuracy of OPCS coding in surgical discharge summaries within a specific department.
- To quantify the financial impact of incorrect procedural coding.
- To develop and implement a targeted intervention to improve coding accuracy.
Main Methods:
- A baseline audit was conducted over two months to determine the initial rate of incorrect OPCS coding.
- A specific OPCS coding table was developed collaboratively with clinical coders and surgeons.
- The coding table was disseminated to junior doctors responsible for completing discharge summaries.
- A re-audit was performed to evaluate the impact of the intervention on coding accuracy.
Main Results:
- Baseline audit revealed that 32% of operations were incorrectly coded.
- Incorrect coding resulted in an estimated financial loss of £17,000 to the Trust.
- Post-intervention re-audit demonstrated 100% accuracy in OPCS coding for all operations.
- The developed coding table proved effective in improving procedural coding quality.
Conclusions:
- Specifically designed coding tables can significantly enhance the accuracy of procedural coding in surgical discharge summaries.
- Accurate OPCS coding ensures correct hospital reimbursement and improves the quality of clinical documentation.
- Implementing tailored coding aids across surgical departments is recommended to optimize financial and clinical outcomes.
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