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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...

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Autores principales: Martinou, Eirini, Shouls, Genevieve, Betambeau, Nadine
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
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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.
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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
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