Clinical coding policy inpatient services

1 Policy summary

This policy provides information in relation to clinical coding for which is externally sourced for mental health, rehabilitation, community inpatients (physical health) and hospice inpatient services for the trust. It details the framework and responsibilities to ensure clinical coding is completed to a satisfactory standard.

2 Introduction

Clinical coding is a health administration function that involves the translation of written clinical statements into a nationally and internationally recognised coded format. A clinical coder will analyse information about an episode of patient care and assign standardised alphanumeric codes for both diagnoses and procedures or interventions using the relevant classification system.

The International Classification of Diseases 10th Revision, commonly known as ICD10, has been devised by the world health organisation (WHO) and its codes, which cover all reasons for patients’ admissions to hospital are widely used internationally. The codes included in the office of population censuses and Surveys 4th Revision, commonly known as OPCS4, cover all operative procedures and interventions that patients have undergone during their hospital stay.

These codes are used in the United Kingdom only. Full and accurate coding of activity in the NHS can be essential for service delivery, achieving targets, resource management, clinical governance, and performance management. Coded clinical data which is validated and audited is more likely to be recognised as an accurate reflection of hospital activity.

Guidance from assertion 3 of the data security and protection toolkit (DSPT) (opens in new window) stipulates that an organisation must ensure that all of its clinical coders are sufficiently trained so that they maintain the highest standards of clinical coding. Focused data quality audit on clinical coding is a crucial part of a robust assurance framework and guidance from assertion 1 of the DSPT, which stipulates that it must be audited either via a continuous programme or via a single audit annually.

3 Purpose

To provide complete, accurate and timely coded clinical information within our clinical system (TPP SystmOne).
To ensure that the trust’s clinical coding is in adherence to the NHS England national clinical coding standards.
To achieve and maintain high standards of clinical coded information.

4 Scope

This document applies to and is relevant across the following
services or departments or care groups:

all inpatient activity across the trust’s portfolio (excluding New beginnings drugs and alcohol services) as follows:
- Doncaster Mental Health, Brodsworth, Cusworth, Windermere Lodge, Skelbrooke, Emerald Lodge and Amber Lodge
- Doncaster Physical Health, Magnolia Lodge, Hazel and Hawthorne
- Doncaster St John’s Hospice
- Rotherham Mental Health, Osprey, Sandpiper, Brambles, Glade, Kingfisher and Goldcrest
- North Lincs Mental Health, Mulberry and Laurel
all employee’s (clinical and non-clinical) involved in the clinical coding process for inpatients

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

Please note, there is no national requirement to code community patient records for either physical or mental health, however it is recognised that some services have adopted this as a principle of good practice and undertake clinical coding at service level. There is no specific resource or training for this activity.

The clinical coding contract in place for inpatients services does not extend to community for this reason.

5 Procedure or implementation

5.1 Quick guide

5.1.1 Provision of clinical coding

Clinical coding for inpatient activity will be performed by externally sourced, experienced and accredited clinical coder.
The clinical coder will connect to TPP SystmOne using a trust laptop via health and social care network or via an alternative secure connectivity solution.

5.1.2 Source documentation

Discharge summary.
Referral letter.
Medical history.
Doctor’s notes.
Historical communications and letters.
Tabbed journal entries.

5.1.3 Timeframe

Coding is completed within four weeks of the activity being recorded in TPP SystmOne.

5.1.4 Monitoring of activity

The clinical coder will provide a monthly update to the Information quality officer confirming the number of FCEs completed and the number of uncoded episodes outstanding for each specialty.

5.1.5 Audit

To maintain compliance with assertion 1 of the DSPT, the trust commissions an annual audit to examine coded activity and the supporting framework to provide an opinion on whether the trust is adhering to the NHS England national clinical coding standards.
Findings are reported to the data quality and process improvement group (DQPIG) who are responsible for overseeing completion of any actions arising from the audit.

5.2 Provision of clinical coding

Clinical coding for inpatient activity will be performed centrally within Health Informatics by an externally sourced, experienced and accredited clinical coder.

The clinical coder assigned to the trust will provide up to date certificates to evidence they are sufficiently trained to maintain the standards of clinical coding.

The clinical coder will connect to TPP SystmOne using a trust laptop via health and social care network or via an alternative secure connectivity solution.

The clinical coder will provide onsite support for clinical coding audits and other appropriate site action where required.

The contract with the external provider will be reviewed in accordance with the agreed contract.

5.3 Source documentation

The clinical coder will review the following templates or documentation within TPP SystmOne to enable them to perform coding. This list is not exhaustive and in some cases, the coder is expected to review the full patient record.

Discharge summary.
Referral letter.
Medical history.
Doctor’s notes.
Historical communication and letters.
Tabbed journal entries including:
- nursing
- physiotherapy, occupational therapy, psychology, speech and language therapy, palliative care
- tissue viability
- laboratory test results
- medical imaging results
- MDT meeting
- subjective, objective, medication, risk, assessment, plan (S.O.M.R.A.P)

The source data should include:

primary diagnosis
secondary diagnosis
primary procedures
secondary procedures
co-morbidities
complications of treatment
relevant physical findings or investigation results
any known allergies
identified risks including any infection risks
factors leading to delayed discharge

If any part of the clinical record is unclear, the coder must contact the relevant clinician for clarification.

5.4 Application

The clinical coder will enter the relevant ICD-10 and OPCS-4 codes into the clinical coding screen following the process described in the TPP SystmOne clinical coding guide (opens in new window).

Some patients may have more than one FCE if they have transferred consultant during their inpatient stay; all episodes need to be coded.

The clinical coding screen within TPP SystmOne allows the clinical coder to manage coding so that they can easily see which patient records:

have not been coded
have been partially coded
need authorising

5.5 Timeframe

There is a requirement that coding is completed within four weeks of the activity being recorded in TPP SystmOne.

5.6 Escalation of data quality issues

The clinical coder must escalate any data quality issues identified within the patient record to the information quality officer.

6.7 Monitoring of activity

The clinical coder will provide a monthly update to the information quality officer confirming the number of FCEs completed and the number of uncoded episodes outstanding for each specialty.

Performance against the contract will be monitored with any under performance escalated to the director of health informatics.

5.8 Supervision of clinical coder

The information quality officer will act as a point of contact for the clinical coder for any trust related matter.

Externally contracted coders will be provided with professional support, advice, supervision and training by the supplier.

5.9 Commissioning data sets (CDS) previously known as secondary uses service (SUS) submission

RePortal report ‘345, submissions, SUS ICD codes’ displays all ICD-10 and OPCS4 codes applied to each FCE that will filter into the monthly SUS submission.

5.10 Audit

To maintain compliance with assertion 1 of the DSPT, the trust commissions an annual audit to examine coded activity and the supporting framework to provide an opinion on whether the trust is adhering to the NHS England national clinical coding standards.

Findings are reported to the data quality and process improvement group (DQPIG) who are responsible for overseeing completion of any actions arising from the audit.

6 Training implications

As a trust policy, all employee’s or colleagues need to be aware of the key points that the policy covers. Employee’s can be made aware through:

one to one meetings or supervision
continuous professional development sessions
special meetings
intranet
team meetings
local induction

7 Equality impact assessment screening

To download the equality impact assessment associated with this policy please follow the link: EIA.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own
decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the Principles of the Mental Capacity Act (2005).

8 Links to any other associated documents

9 References

10 Appendices

10.1 Appendix A Responsibilities, accountabilities and duties

10.1.1 Medical leadership

The executive medical director, deputy medical directors and associate medical directors are responsible for ensuring that medical colleagues provide the requisite information in TPP SystmOne.

10.1.2 Frontline medics

Consultants and doctors providing direct clinical care in mental health settings are responsible for recording a comprehensive primary diagnosis for each finished consultant episode (FCE) and translating into an ICD-10 code. Fourth characters in mental health codes (F codes) supply a level of detail about a condition that a clinical coder is not trained to interpret, such as the level of impairment a condition has on a person’s behaviour or traits or features that manifest themselves during the course of a disorder that will alter the fourth character.

All consultants and doctors are responsible for the completion of GP discharge summaries which align to nationally mandated headings.

Consultants and doctors should be available to the clinical coder (by MS Teams, telephone or email) to ensure that any queries are answered in a timely manner.

10.1.3 Clinical inpatient colleagues

Clinical inpatient colleagues are responsible for maintaining accurate and comprehensive record keeping throughout a patient’s episode in hospital in line with the trust’s healthcare record keeping policy; this will form the source data for the clinical coder.

On nurse led wards, the clinical ward staff will coordinate and facilitate a timely and individualised discharge planning process with the support of the full active multidisciplinary team (MDT) and are responsible for completing and sending discharge summaries to GPs. These should include, as far as possible, the items listed under the ‘frontline medics’ section of this document.

10.1.4 Administrative colleagues support clinical inpatient services

Administrative colleagues should ensure that discharge summaries are completed comprehensively, accurately and in a timely manner in line with the ‘admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures’.

10.1.5 Director of health informatics

The director of health Informatics is responsible for ensuring there is a trust policy and procedure in place for the provision of centralised clinical coding and for the ongoing monitoring of its application.

10.1.6 Head of information governance

The head of information governance is responsible for maintaining compliance with assertions 1 and 3 of the DSPT and ensuring any improvement plans arising from annual audits are completed within the agreed timeframes.

10.1.7 Head of information quality

The head of information quality is responsible for maintaining the external contract for provision of clinical coding and for coordinating annual audits.

10.1.8 Information quality officer

The information quality officer will support the head of information quality to maintain the external contract for provision of clinical coding and will be a point of contact for the clinical coder.

The postholder will be a point of contact for the annual audit and will lead on any improvement plans arising from findings.

They are also responsible for ensuring the completeness of data submitted to CDS or SUS and for managing any data quality issues identified.

The information quality officer will investigate all data quality issues highlighted to them by the clinical coder and ensure that known errors in the clinical record are corrected in accordance with the healthcare record keeping policy if or as appropriate. The owner of the data errors will be agreed on a case by case basis. They will also ensure that any emerging themes and trends are identified and highlighted to the appropriate staff group or manager to promote lessons learnt.

10.1.9 Clinical Systems team

The Clinical Systems team are responsible for maintaining the TPP SystmOne clinical coding guide (opens in new window) and keeping the clinical coder up to date on any system specific configuration or updates that may impact on them performing coding.

They are a point of contact for the clinical coder to assist with system related queries and can assist with configuring a suitable view to enable shortcuts and efficiencies associated with the trawl of a patient record.

10.1.10 Clinical coder

The clinical coder will translate written clinical statements from the source documentation into the appropriate coded format, using the classifications WHO ICD10 5th Edition Volumes 1 to 3 and OPCS 4.10 Volumes 1 and 2, whilst adhering to the rules and conventions as set out in the NHS England national clinical coding standards.

10.2 Appendix B Monitoring arrangements

10.2.1 Application of policy

How: Annual audit.
Who by: External specialist.
Reported to: Information governance group or DQPIG.
Frequency: Annually.

10.2.2 Adherence to the NHS England national clinical coding standards

How: Annual audit.
Who by: External specialist.
Reported to: Information governance group or DQPIG.
Frequency: Annually.

10.2.3 Contract with external supplier

How: Review as per contract.
Who by: Head of data quality or information quality officer.
Reported to: Executive Management team.
Frequency: Review as per contract.

10.2.4 CDS or SUS submission

How: Monthly sign off process.
Who by: Head of data quality or information quality officer.
Reported to: DQPIG.
Frequency: Monthly.

Document control

Version: 2.1.
Unique reference number: 546.
Approved by: Corporate policy approval group.
Date approved: 25 January 2024.
Name of originator or author: Information quality officer.
Name of responsible individual: Director health informatics.
Date issued: 25 January 2024.
Review date: 30 June 2026.
Target audience: Operational management, clinical, medical and administrative support staff.

Page last reviewed: April 15, 2024
Next review due: April 15, 2025

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