Clinical coding for inpatient and community services policy

1 Document summary

This policy sets out the framework for the accurate, timely and standardised recording of clinical coding across inpatient and community services within the trust. Clinical coding is the process of translating clinical information from patient records into recognised alphanumeric codes, primarily using the International Classification of Diseases (ICD‑10) for diagnoses and OPCS‑4.1. High-quality clinical coding is essential to support patient care, clinical governance, service planning, performance monitoring, and national reporting requirements.

The policy applies to all services where a diagnosis is recorded. For inpatient activity, clinical coding is undertaken centrally by an externally contracted, accredited clinical coder. For community services, coding is completed by the diagnosing clinician, with administrative support where appropriate. All coding is recorded within the trust’s clinical system (SystmOne).

Clear expectations are set regarding the timeliness of coding. Inpatient episodes must be coded within four weeks of completion, while community diagnoses should be coded within 24 hours of being made. The policy outlines how changes to diagnoses should be managed, ensuring that patient records remain accurate and reflect clinical decision-making over time.

The policy emphasises the importance of comprehensive and high-quality source documentation. Clinical coders and clinicians must rely on detailed records including discharge summaries, clinical notes, investigation results, and multidisciplinary team input. Where documentation is unclear, coders are required to seek clarification from the relevant clinician to ensure accuracy.

Clinical colleagues are responsible for recording accurate and complete clinical information, including diagnoses and discharge summaries. The external clinical coder is responsible for applying coding standards correctly. The information quality officer provides oversight, manages data quality issues, and acts as the main point of contact for the coding function. The chief digital information officer holds overall accountability for ensuring effective systems, contractual arrangements, and policy implementation.

Monitoring and quality assurance is set out around coding performance, completeness, and compliance with NHS England national clinical coding standards. Identified data quality issues are investigated and addressed, with learning shared across services to support continuous improvement.

The policy aligns with the Data Security and Protection Toolkit requirements, ensuring that coded clinical data is regularly reviewed and improved. It is supported by related trust policies, including those on healthcare record keeping, information governance, and patient flow, to provide a consistent and integrated approach to managing clinical information.

2 Introduction and aim

Clinical coding is a health administration function that involves the translation of written clinical statements into a nationally and internationally recognised coded format. For our inpatient services 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. For our community services the diagnosing clinician (or administrative colleagues) will add the standardised alphanumeric code to the patient record.

The International Classification of Diseases 10th Revision, commonly known as ICD-10, has been devised by the World Health Organisation (WHO) and its codes, which cover all diagnoses are used internationally.

The codes included in the Office of Population Censuses and Surveys 4th Revision, commonly known as OPCS4.11, cover all operative procedures and interventions that patients have undergone during their hospital stay. These codes are used in the United Kingdom only. Procedure codes are added for inpatients 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 is more likely to be recognised as an accurate reflection of activity.

The Data Security and Protection Toolkit (DSPT) Principle: E4.b Clinical coding requires that “You are committed to regularly evaluating and improving your organisation’s coded clinical data”.

2.1 Aim

• To provide complete, accurate and timely coded clinical information within our clinical system (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.

3 Procedure

This document applies to and is relevant across all services where a diagnosis is formulated. The only exception to this is Hazel and Hawthorne (physical health wards) where the patient has been diagnosed at the acute hospital, but the clinical coding is still added at discharge from the trust.

3.1 Provision of clinical coding for inpatients (not relevant to community 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 SystmOne using a trust laptop via health and social care network or via an alternative secure connectivity solution.

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

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

3.2 Source documentation

The clinical coder will review the following templates or documentation within 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
  • multidisciplinary team (MDT) meeting notes
  • subjective, objective, medication, risk, assessment, plan (SOMRAP)

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.

3.3 Application

The clinical coder will enter the relevant ICD-10 and OPCS-4.11 codes into the clinical coding screen following the process described in the SystmOne clinical coding guide.

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

The clinical coding screen within 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

3.4 Timeframe

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

3.5 Escalation of data quality issues

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

3.6 Monitoring of activity

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

Performance against the contract will be monitored with any underperformance escalated to the chief digital information officer.

3.7 Supervision of clinical coder

The information quality officer (IQO) 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.

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

RePortal report “345, submissions, SUS ICD codes” displays all ICD-10 and OPCS4.11 codes applied to each finished consultant episode (FCE) that will filter into the monthly secondary uses service submission.

3.9 Audit

To maintain compliance with the Data Security and Protection Toolkit (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 Finance Digital and Estates Committee (FDE) who are responsible for overseeing completion of any actions arising from the audit.

3.10 Provision of clinical coding for community (not relevant to inpatient coding)

Community clinical coding should be added to the patient record within 24 hours of the diagnosis being formulated, in accordance with the trust’s healthcare record keeping policy.

There is only a requirement to clinically code the diagnosis being given by a diagnosing clinician at that time.

It can be expected that in some cases diagnoses may change and also some cases where one clinician or clinical team gives one diagnosis, but the patient then comes under a different clinical team who feel an alternative diagnosis may be more correct.

Within the same referral:

• where it is the case that the old diagnosis is correct but no longer the primary concern, the old code should be kept, a new code should be added, and the new diagnosis coded and ordered above the old diagnosis; the responsibility for doing this sits with the clinician now giving the new diagnosis, with data entry possibly supported by administrative colleagues
• where a diagnosis is felt to be incorrect, this should be noted, and the new diagnosis coded and ordered above the old diagnosis clearly highlighting the change; the responsibility for these sits with the diagnosing clinician
• where an incorrect code is added in error and identified immediately, this can be deleted from SystmOne

If coding is felt to be incorrect for a different referral:

• coding can only be amended within the SystmOne unit that it was coded in
• where the referral was for a different team and the diagnosis is felt to be incorrect, it is for the clinician who gave the original diagnosis the decide if this needs amending or editing as above.

4 Responsibilities

4.1 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 SystmOne.

4.2 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). For community these should also be translated into an ICD-10 code and added directly onto the patient record (with support from administration colleagues where available). For inpatients, the ICD-10 code will be added to the patients record by the contracted clinical coder. There may be times when the clinical coder needs to clarify coding with the medical team. If required, the medical team should make themselves available via email, phone, or Microsoft Teams to the coder to address any queries in a timely manner.

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

4.3 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, clinical colleagues 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.

4.4 Clinical community colleagues

Clinical community colleagues are responsible for maintaining accurate and comprehensive record keeping throughout a patient’s episode of care in line with the trust’s healthcare record keeping policy. Community clinical coding should be added to the patient record within 24 hours when a diagnosis is confirmed or considered provisional (and marked appropriately if so). There will be cases where no diagnosis (and therefore no coding) is appropriate, so teams are unlikely to ever achieve 100% coding of their referrals. Team managers are responsible for monitoring the coding activity within their teams with a report available in the trust reporting system to facilitate this.

4.5 Administrative colleagues supporting clinical 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. Members of the Data Quality Group will monitor compliance according to their respective care groups. Additionally, some teams or services may ask administrative colleagues to enter the coding on behalf of the diagnosing clinician, the coding guide should be followed as normal as this explains how to enter the diagnosing clinician.

4.6 Chief digital information officer

The chief digital information officer 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. They are also responsible for maintaining the external contract for provision of clinical coding and for coordinating annual audits.

4.7 Head of information governance

The head of information governance is responsible for maintaining compliance with assertions of the Data Security and Protection Toolkit (DSPT) and ensuring any improvement plans arising from annual audits are completed within the agreed timeframes.

4.8 Information quality officer

The information quality officer (IQO) will support the chief digital information officer 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 commissioning data sets (CDS) or secondary uses service (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 colleague group or manager to promote lessons learnt.

4.9 Clinical Systems team

The Clinical Systems team are responsible for maintaining the SystmOne clinical coding guide 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.

4.10 Clinical coder

The clinical coder will translate written clinical statements from the source documentation into the appropriate coded format, using the classifications WHO ICD-10 5th Edition Volumes 1 to 3 and OPCS 4.11 Volumes 1 and 2, whilst adhering to the rules and conventions as set out in the NHS England national clinical coding standards.

5 Training

There are no specific training needs in relation to this policy, but colleagues will need to be familiar with its contents: and any other individual or group with a responsibility for implementing the contents of this policy.

The external contractors for inpatient clinical coding are responsible for keeping their own training requirements up to date.

6 Monitoring arrangements

6.1 Application of policy

• How: annual audit.
• Who by: external specialist.
• Reported to: Information Governance Group or Finance Digital and Estates Committee (FDE).
• Frequency: annually.

6.2 Adherence to the NHS England national clinical coding standards

• How: annual audit.
• Who by: external specialist.
• Reported to: Information Governance Group or Finance Digital and Estates Committee (FDE).
• Frequency: annually.

6.3 Contract with external supplier

• How: review as per contract.
• Who by: chief digital information officer or information quality officer (IQO).
• Reported to: Executive Management team.
• Frequency: review as per contract.

6.4 Commissioning data sets (CDS) or secondary uses service (SUS) submission

• How: monthly sign off process.
• Who by: chief clinical information officer.
• Reported to: Finance Digital and Estates Committee (FDE).
• Frequency: monthly.

7 Related documents

• Healthcare record keeping policy
• Admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures
• Information governance policy and management framework (includes data protection policy content)
• SystmOne clinical coding guide

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Page last reviewed: July 02, 2026
Next review due: July 02, 2027

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