View June's Board Pack - Royal Bournemouth Hospital

■■■■same site at the same theatre visit, only the therapeutic procedureshould be recorded. This was the cause of all of the HRG changeswithin Cardiology;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. The coder had not reflected thedifferent site of procedures within the codes allocated and continued touse only codes from chapter ‘S’ when sometimes the correct codesshould be from other specific chapters. For example skin operation onthe ear should be coded using a code from chapter ‘D’ with a code fromchapter ‘S’ to enhance this. All coders must have this rule re-enforced toensure these are coded correctly;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;the Coding Manager needs to work with clinical staff to re-enforce theneed that all information in the casenotes should be duplicated on theelectronic patient record as this is the source document for coding; andthe specific type of image control needs to be documented within thecasenotes and the EPR. The coding of Cardiology procedures could bemore specific if this information is available to the coder.RecommendationsR1 Stop recording Angiogram codes when Angioplasty procedures areundertaken and remove the policy regarding this from the coding policy andprocedure document. Coders should be instructed to use only appropriatecodes 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 the co-morbidities from the March 2010 Coding Clinic mustbe followed by all coders and clinicians.R4 Target training to clinical staff on the use of image control to berecorded more accurately to identify the specific type of imaging oncardiology procedures.R5 (R6 in 2009/10) Review and share results with Medical Records UserGroup, the organisation of casenotes to agree on an action plan forimproving record keeping standards (to improve ease of use and so codingaccuracy / speed).R6 (R9 in 2009/10) Update the system to code directly to ICD-10 andOPCS 4.5 codes thereby avoiding the intermediate step of using clinicalTerminology (READ codes).Audit Commission Payment by results data assurance framework 14