Nursing Management (Harrow)

Gaming and up-coding: do nurses up-code patient dependency levels? Keith Hurst participated in a study that suggests that nurse managers should check for inconsistencies in ward information.(applied leadership)


DIAGNOSIS AND PROCEDURE coding, used in the UK since 1944, has expanded and undergone revision in recent years. Traditionally, codes have been used for auditing and research, and nowadays patients can generate several codes, including International Classification of Diseases (ICD) 10 and Office for Population Census and Survey (OPCS) 4.4 procedure codes.

These are used to determine a patient's healthcare resource group (HRG), or diagnostic-related group (DRG) as it is known in some countries, which is used in England under the Payment by Results (PbR) system to pay acute trusts for the work they do. Northern Ireland, Scotland and Wales, however, do not use HRGs to reimburse trusts.

Coding accuracy relies on precise and timely information, which is ultimately converted into HRGs and trust income.

Treatment 'spells', or care episodes from admission to discharge, are based on finished consultant episodes (FCEs) so clinicians are the best coders (Britton et al in press, Department of Health (DH) 2004, 2007), but generally, codes are assigned by dedicated clinical coders, including some with nursing backgrounds.

They obtain information from doctors' records, often hand-written, notoriously hard to read and sometimes incomplete.

The average number of pages in a set of NHS case notes has increased four-fold in the past 20 years, and coders often refer queries to clinicians, which is a bad use of the time of both sets of professionals (Audit Commission 2008, Warner 2004).

Coding problems

Financial survival, commissioning, service planning, especially workforce planning, research and development all depend on accurate hospital patient activity statistics. But well recognised and long-standing coding problems exist (Benson 1990).

For example, up to 40 per cent of some types of patient intervention are under-reported, and accuracy rates of 91 per cent diagnostic and 70 per cent procedural coding leave much to be desired. The Audit Commission's (2008) detailed study suggests that:

* Almost 10 per cent of bills that service providers send to primary care trusts (PCTS) are based on incorrect diagnostic and treatment codes.

* Coding error rates vary across acute trusts by between 0.3 and 52 per cent, the average being 17 per cent, and this leads to under- and over-charging.

Of 100 patients that Britton et al (in press) studied in detail, four were not coded because of lost case notes, while only 34 of the remaining patients' codes assigned independently by full-time coders and clinicians were accurate. In the same study, 62 cases had discrepancies and 28 were assigned to wrong HRGs, leading to under- or over-charging.

The main problem seemed to be that around one third of patients were given one code by full-time coding staff, while clinicians applied a range of different codes, so that more than one quarter of patients ended up with incorrect HRGs. A single patient episode could therefore be assigned a variety of different codes or code combinations, because determining the appropriate code was inconsistent. …

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