View June's Board Pack - Royal Bournemouth Hospital

KEYDESCRIPTIONcoding. This is where information regarding the episode becameavailable after the episode was coded. This error key is not to be used ifthe information was not accessed by the Clinical Coder at the point ofcoding, for example, with histopathology reports.This error key would also be assigned by the Auditor when the sourcedocumentation used at the time of coding did not contain all pertinentinformation required for accurate and complete coding and the Coder didnot have access to this information, for example, coding from proformawith no access to the casenotes.PDDPRIMARY DIAGNOSISDOCUMENTATION ISSUEThe Auditor is unable to code the clinical data from the sourcedocumentation and compare against that of the Trusts due to unclear orinconsistent information.For example:Inconsistency between information recorded by clinical staff contained onthe source documentation and it is not clear which is correct.The source documentation is illegible.PDMPRIMARY DIAGNOSIS CODEDTO MANAGEMENTSPECIFICATIONThere is a clear and documented directive from management tocontravene coding to national standards.For example:by unbundling diagnoses or procedures into component partsby adding or optimising the coded clinical data to alter the derived HRG.PDCPRIMARY DIAGNOSIS CODEDTO CLINICIAN SPECIFICATIONThere is a clear and documented directive from Clinicians to contravenecoding to national standards or capture those instances where a Clinicianhas requested that coding be done in a particular way as it moreaccurately captures the diagnosis.For example:by unbundling diagnoses or procedures into component parts.PDSCPRIMARY DIAGNOSIS CODEDDUE TO SYSTEM CONSTRAINTDue to the system that the Organisation uses the primary diagnosis codesis technically incorrect at some level, omitted or sequenced incorrectly.Secondary diagnosis error key descriptionsCoder ErrorSD3SECONDARY DIAGNOSISINCORRECT AT THREECHARACTER LEVELThe secondary diagnosis code has been allocated to an incorrect threecharacter code.SD4SECONDARY DIAGNOSISINCORRECT AT FOURAudit Commission Payment by results data assurance framework 73