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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
18 A full action plan for the PCT is at appendix 1 with an action plan for theTrust at appendix 2. The detailed report and appendices 3, 4, 5 and 6expand on the audit findings and provide evidence for the actions to supportimprovement. The appendices are aimed primarily at specialist coding staffat the Trust and will be of interest to commissioners where there are specificissues arising from the audit.Next steps19 The findings from this audit will be discussed and agreed with the Trustand PCT on 3 February 2011 and the organisations should use theirestablished arrangements to monitor and follow up the issues andrecommendations agreed in the report. The results of this audit should beshared with other PCTs commissioning services from The RoyalBournemouth and Christchurch Hospitals NHS Foundation Trust.20 We will publish a summary of the key results on the Audit Commission’swebsite when all audits in 2010/11 are completed and reported to PCTs andtrusts. Our website also contains details of the other aspects of theprogramme. This includes national briefings, case studies and free accessto the National Benchmarker for NHS organisations.21 Providing assurance over the quality of underpinning data remains akey consideration for the PbR system. This will increase with the plans tomove the PbR tariff into areas such as mental health, community servicesand the further development of linking payments to outcomes. The AuditCommission will continue to undertake this role whilst it and PCTs exist. Wewill work with the Department of Health, the new NHS CommissioningBoard, Monitor and the Information Centre to ensure these crucial checksremain within the payment system in the future and will be consulting in2011 regarding the future direction of the programme for 2011/12 onwards.Audit Commission Payment by results data assurance framework 6
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