View June's Board Pack - Royal Bournemouth Hospital

Key areas for improvements15 The key areas for the Trust to improve the coding accuracy are:■ removal of the policy regarding the use of a secondary procedure codefor angiograms when an angioplasty is undertaken. These are codeddue to clinical staff insisting these codes are added when an angiogramis done at the same time as an angioplasty;■ provide training to the coders covering how skin procedures should becoded, as these can be coded in two ways depending on the site of thebody that has been operated on;■ reinforce the importance of recording the mandatory co-morbidities fromthe March 2010 Coding Clinic, as omission of secondary diagnoses wasan issue from both the coder and clinical perspective; and■ the clinical staff need to be informed that all information in thecasenotes should be duplicated on the electronic patient record as thisis the source document for coding.Recommendations16 Accurate coding supports accurate data. This information is used notonly for billing purposes, but for planning by both the Trust and allcommissioners. We followed up the progress on the 12 recommendationsfrom our 2009/10 report, including one outstanding since 2008/09. The Trusthas fully implemented 10 of the 12 recommendations, which is satisfactory.Recommendation 6 in 2009/10 on improvements in the standard ofcasenotes has not been implemented but this has little impact on the qualityof coding as casenotes are not used as the source document in the Trust.The coders use the electronic discharge summary with the EPR and thiswould only impact on the few episodes when the coder would need toaccess the information in the casenotes due to poor information held withinthe electronic discharge summary or electronic patient record.17 The PCT and Trust should ensure that all recommendations arefollowed up and implemented in order to support the improvement in coding.The key recommendations for each organisation are noted below.High priority recommendations for the TrustR1 Stop recording Angiogram codes when Angioplasty procedures areundertaken and remove the policy regarding this from the coding Policyand Procedure document. Coders should be instructed to use onlyappropriate codes in cardiology episodes.R2 Train coders to follow the guidance regarding skin procedures at thebeginning of OPCS chapter S and when to use codes from chapter S orspecific body system codes.R3 Recording of co-morbidities from the March 2010 Coding Clinic must befollowed by all coders and clinicians.Audit Commission Payment by results data assurance framework 5