Cargando…
Improving the accuracy of operation coding in surgical discharge summaries
Procedural coding in surgical discharge summaries is extremely important; as well as communicating to healthcare staff which procedures have been performed, it also provides information that is used by the hospital's coding department. The OPCS code (Office of Population, Censuses and Surveys C...
Autores principales: | , , |
---|---|
Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
British Publishing Group
2014
|
Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645875/ https://www.ncbi.nlm.nih.gov/pubmed/26734286 http://dx.doi.org/10.1136/bmjquality.u202053.w1990 |
_version_ | 1782400884277248000 |
---|---|
author | Martinou, Eirini Shouls, Genevieve Betambeau, Nadine |
author_facet | Martinou, Eirini Shouls, Genevieve Betambeau, Nadine |
author_sort | Martinou, Eirini |
collection | PubMed |
description | Procedural coding in surgical discharge summaries is extremely important; as well as communicating to healthcare staff which procedures have been performed, it also provides information that is used by the hospital's coding department. The OPCS code (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures) is used to generate the tariff that allows the hospital to be reimbursed for the procedure. We felt that the OPCS coding on discharge summaries was often incorrect within our breast and endocrine surgery department. A baseline measurement over two months demonstrated that 32% of operations had been incorrectly coded, resulting in an incorrect tariff being applied and an estimated loss to the Trust of £17,000. We developed a simple but specific OPCS coding table in collaboration with the clinical coding team and breast surgeons that summarised all operations performed within our department. This table was disseminated across the team, specifically to the junior doctors who most frequently complete the discharge summaries. Re-audit showed 100% of operations were accurately coded, demonstrating the effectiveness of the coding table. We suggest that specifically designed coding tables be introduced across each surgical department to ensure accurate OPCS codes are used to produce better quality surgical discharge summaries and to ensure correct reimbursement to the Trust. |
format | Online Article Text |
id | pubmed-4645875 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2014 |
publisher | British Publishing Group |
record_format | MEDLINE/PubMed |
spelling | pubmed-46458752016-01-05 Improving the accuracy of operation coding in surgical discharge summaries Martinou, Eirini Shouls, Genevieve Betambeau, Nadine BMJ Qual Improv Rep BMJ Quality Improvement Programme Procedural coding in surgical discharge summaries is extremely important; as well as communicating to healthcare staff which procedures have been performed, it also provides information that is used by the hospital's coding department. The OPCS code (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures) is used to generate the tariff that allows the hospital to be reimbursed for the procedure. We felt that the OPCS coding on discharge summaries was often incorrect within our breast and endocrine surgery department. A baseline measurement over two months demonstrated that 32% of operations had been incorrectly coded, resulting in an incorrect tariff being applied and an estimated loss to the Trust of £17,000. We developed a simple but specific OPCS coding table in collaboration with the clinical coding team and breast surgeons that summarised all operations performed within our department. This table was disseminated across the team, specifically to the junior doctors who most frequently complete the discharge summaries. Re-audit showed 100% of operations were accurately coded, demonstrating the effectiveness of the coding table. We suggest that specifically designed coding tables be introduced across each surgical department to ensure accurate OPCS codes are used to produce better quality surgical discharge summaries and to ensure correct reimbursement to the Trust. British Publishing Group 2014-10-21 /pmc/articles/PMC4645875/ /pubmed/26734286 http://dx.doi.org/10.1136/bmjquality.u202053.w1990 Text en © 2014, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/http://creativecommons.org/licenses/by-nc/2.0/legalcode |
spellingShingle | BMJ Quality Improvement Programme Martinou, Eirini Shouls, Genevieve Betambeau, Nadine Improving the accuracy of operation coding in surgical discharge summaries |
title | Improving the accuracy of operation coding in surgical discharge summaries |
title_full | Improving the accuracy of operation coding in surgical discharge summaries |
title_fullStr | Improving the accuracy of operation coding in surgical discharge summaries |
title_full_unstemmed | Improving the accuracy of operation coding in surgical discharge summaries |
title_short | Improving the accuracy of operation coding in surgical discharge summaries |
title_sort | improving the accuracy of operation coding in surgical discharge summaries |
topic | BMJ Quality Improvement Programme |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645875/ https://www.ncbi.nlm.nih.gov/pubmed/26734286 http://dx.doi.org/10.1136/bmjquality.u202053.w1990 |
work_keys_str_mv | AT martinoueirini improvingtheaccuracyofoperationcodinginsurgicaldischargesummaries AT shoulsgenevieve improvingtheaccuracyofoperationcodinginsurgicaldischargesummaries AT betambeaunadine improvingtheaccuracyofoperationcodinginsurgicaldischargesummaries |