Information about patient care plays an essential part in the delivery of health services in Wales. It’s used to plan and evaluate services, monitor trends and highlight areas of health concerns.
For this reason the information needs to be recorded accurately – and it’s where the national Clinical Classifications Team, within the NHS Wales Informatics Service, has a major role to play.
The team provides advice and assurance to around 250 clinical coders working in Welsh hospitals, undertakes essential audit to ensure accuracy in both coding and clinical documentation, and also manages essential and on-going training.
Richard Burdon, who leads the Classifications Team, explained: “Every day thousands of Welsh patients undergo treatment and care in our hospitals and their diagnosis and any procedures are recorded in a coded format by the clinical coders.”
The coders use the systems ICD-10 (International Classification of Diseases) for diagnosis and OPCS-4 (Office of Population Censuses and Surveys Classification of Interventions and Procedures) for recording medical procedures.
It’s certainly an intensive job as coders have to extract relevant clinical information from largely handwritten medical notes, of varying quality, assign appropriate codes and enter the information on a computer database.
Richard explained: “Coders need great attention to detail, to have detective skills and to be able to regularly discuss clinical diagnoses and procedures with consultants. Sometimes documentation is missing, or the clinician needs to clarify the notes, or the handwriting is difficult to read and the coder has to make sense of all of this, as well as assigning codes using the classifications volumes. For example where a clinician notes that a patient has “cognitive impairment” –this specific diagnostic phrase is not indexable within the ICD-10 classification, although “mild cognitive impairment” is. The coder would have to go back and find out more information from the responsible consultant.”
Clinical coding is now more important than it’s ever been. In Wales coded information is used to provide ‘the big picture’ of healthcare delivery and to spot trends. It’s used in many different systems, and presented in different formats including Health Maps Wales. It has been crucial in informing decisions around the reconfiguration of health services in Wales. This is why accuracy of coding is so important.
In addition to use within Wales, the coded data is submitted to the World Health Organisation (WHO) for global analysis of healthcare. In order to support this, clinical coding is about to begin using a brand new standard which will allow the accurate recording of the Zika virus on a global scale. The data are also used to support benchmarking of activity and performance with other UK Home Countries.
With thousands of codes and classifications available, help and advice on classification and coding standards is available from Richard and his team, who are based in the Informatics Service’s Cardiff and Swansea offices. This can include advice on complex coding issues to the coding of new and not yet indexable procedures.
In the latter case, the Classifications Team submit details of the new procedure to the Health and Social Care Information Centre (HSCIC) for further consideration, and contribute to UK discussions on the development of new and enhanced standards for coding.
To support on-going skills development, the Classifications Team manages around 25 coding courses each year. Currently, these are classroom based and as such limit attendance. Moving forward Richard is hoping to introduce more online learning and webinars.
Last year the Classifications Team in partnership with the Wales Audit Office published the first national audit of clinical coding in Wales. This was a milestone for the team and highlighted the importance of coding.
The audit provided evidence that accuracy is comparable with NHS England. Over one year, the audit looked at more than 1,700 individual records in 19 coding departments, across three specialties – General Surgery, Trauma and Orthopaedics, and General Medicine.
However, it also noted that poor and inadequate clinical documentation is having an adverse effect on the quality of clinical coded data, with many paper medical record files not well maintained. While there were many examples of good practice there was variation in performance across health boards.
Increased use of electronic records and documentation within NHS Wales, underpinned by the SNOMED CT clinical terminology, will in future improve the accuracy of coded information across Wales.
Richard welcomes the shift to electronic records as a way of helping improve coding accuracy by reducing or removing the problems inherent in the use of a paper based medical record for clinical coding. In the long-term he recognises that a move to a fully electronic medical record may change the role of the clinical coder. He said: “There will always be a need for clinical coding professionals, but I see it becoming more of an advisory, data quality and audit role in the future if advances such as natural language processing software are applied to electronic health records used across Wales.”
In the meantime NHS Wales relies on the skills and expertise of its clinical coders to provide the information needed to inform decision making and planning.
For more information about clinical coding and classifications contact Richard.Burdon@wales.nhs.uk
Example of a document provided for coding
Dr Smith's Case Notes
Mr Patient was transferred to my care for a LIMA-LAD coronary artery bypass graft with 2xSVG following his NSTEMI the previous week and scans revealing severe atherosclerosis of the coronary arteries. Following the procedure he suffered a slight chest infection, but after treatment with antibiotics he made a good recovery. His comorbidities include Hypertension, COPD and T2 diabetes with retinopathy. He is now fit for discharge.
I25.1 Atherosclerotic heart disease
I21.4 Acute subendocardial myocardial infarction
I10.X Essential (primary) Hypertension
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
E11.3† Type 2 diabetes mellitus with ophthalmic complications
H36.0* Diabetic retinopathy
K45.3 Anatomosis of mammary artery to left anterior descending coronary artery
K40.2 Saphenous vein graft of two coronary arteries
Y80.9 General anaesthetic, unspecified