Clinical Coding Audit: No coding – No Income – No Hospital

Aim: Audit assessing the accuracy of clinical coding by trust guidance on revenue generation. Method: Clinical coding form containing common clinical codes placed at the front of patient notes between July 2014 and August 2014 on a respiratory ward. Medical staff, preferably registrars or consultants, recorded the primary diagnoses and comorbidities on the form. Completed forms sent to the clinical-coding department who supplied the tariff generated. Revenue generated during the test period was compared with the prior two months. Results: Comparable discharges between periods with average revenue generated a difference per patient of £339, totalling a £36,273 increase per month. Conclusion: Simple diagnoses and comorbidities coding forms completed by a senior doctor helped junior doctors improve documentation and accuracy at discharge whilst generating more revenue for the trust.