Payment by results: financial implications of clinical coding errors in urology

Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study

OBJECTIVES

To assess the complications of transrectal (TR) compared to transperineal prostate (TP) biopsies.

PATIENTS AND METHODS

Men diagnosed with prostate cancer between 1 April 2014 and 31 March 2017 in England were identified in the National Prostate Cancer Audit. Administrative hospital data were then used to categorize the type of prostate biopsy and subsequent complications requiring hospital admission. Administrative hospital data were used to identify patients staying overnight immediately after biopsy and those readmitted separately for hospital admissions because of sepsis, urinary retention or haematuria. Procedure-related mortality and total length of hospital stay within 30 days were also recorded. Generalized linear models were used to calculate adjusted risk differences (aRDs).

RESULTS

A total of 73 630 patients undergoing prostate biopsy were identified. Those undergoing TP biopsy (n = 13 723) were more likely to have an overnight hospital stay (12.3% vs 2.4%; aRD 9.7%, 95% confidence interval [CI] 7.1-12.3), were less likely to be readmitted because of sepsis (1.0% vs 1.4%; aRD -0.4%, CI -0.6 to -0.2), and were more likely to be readmitted with urinary retention (1.9% vs 1.0%; aRD 1.1%, CI 0.7-1.4) than those undergoing a TR biopsy (n = 59 907). There were no significant differences in the risk of haematuria or mortality.

CONCLUSIONS

Our results showed that TP biopsy had a lower risk of readmission for sepsis but a higher risk of readmission for urinary retention than TR biopsy. Use of the TP route would prevent one readmission for sepsis in 278 patients at the cost of three additional patients readmitted for urinary retention.

Clinician-directed improvement in the accuracy of hospital clinical coding

'Payment by results' (PbR) remuneration for healthcare services relies on the accurate conversion of diagnoses into Healthcare Resource Group (HRG) codes that are then reimbursed. Inconsistencies in documentation can result in inaccuracies in this process, with consequent implications for measuring activity, disease incidence and organisational performance. The aim of this study was to determine if clinician involvement increases accuracy in the coding of medical cases. Selected records of medical patients admitted to a London NHS trust between November and December 2016 were reviewed by a coding auditor and a clinician. Any changes to the codes and HRG tariff were noted. In total, 123 cases were considered. Changes in code were made on 68 instances, resulting in an overall increase in remuneration of £39,215; an average of £318 per patient. The primary HRG code was changed in 31 cases which accounted for £28,040 of the increase in tariff. In conclusion, clinician involvement can help with documentation ambiguities, thus improving the accuracy of the coding process in a medical setting. Although such collaborative working offers advantages for both the clinician and the coding team, further work is required to investigate the feasibility of this recommendation on a larger scale.

Does a coding sticker for percutaneous nephrolithotomy improve clinical coding accuracy and increase financial remuneration?

Objective:

This study aimed to evaluate whether a coding sticker for percutaneous nephrolithotomy (PCNL), completed by the surgeon after the operation note, improved the accuracy of clinical coding and the financial remuneration for PCNL.

Patients and methods:

A retrospective study was undertaken including all PCNLs performed in a single centre between October 2014 and June 2016. PCNL clinical coding was obtained and applied to yield a Healthcare Resource Group (HRG) code, which was in turn used to calculate the tariff the Trust received for the case. Remuneration and clinical coding accuracy were compared pre- and post-coding sticker introduction.

Results:

Thirty-three cases were included in the study. Eleven patients were reviewed before the introduction of the sticker and 22 after the introduction of the PCNL sticker. Overall mean clinical coding accuracy improved from 65% to 94% after the stickers’ introduction. This resulted in an overall mean increase in remuneration of £501 per case (from £2946 to £3447).

Conclusion:

The implementation of a simple coding sticker for completion after a PCNL improves clinical coding accuracy and increases the financial remuneration.

Can an operative coding sticker improve coding accuracy and remuneration for upper tract stone-related procedures?

Objective:

Rigid ureteroscopy, flexible uretero-renoscopy and ureteric stenting are commonly performed procedures. Operative clinical coding and remuneration varies depending on the procedure. We determined if loss of remuneration, through poor operative coding, could be improved with an operative coding sticker.

Patients and methods:

We performed a retrospective review of 133 random stone-related procedures (rigid ureteroscopy/flexible uretero-renoscopy and ureteric stenting). Using the Office of Population Censuses and Surveys codes, we compared actual operative coding and urological surgeon coding. We introduced an operative coding sticker and prospectively re-audited to determine if coding accuracy improved.

Results:

Flexible uretero-renoscopy was initially miscoded in 29 of 53 cases (55%), with a loss of remuneration of £1014 per case. Rigid ureteroscopies were correctly coded in 99% of cases, but ureteric stenting was only correctly coded in 82%. The introduction of the coding sticker resulted in improved coding accuracy rates of 100% for rigid ureteroscopy, 95% for flexible uretero-renoscopy and 100% for ureteric stenting. Overall, coding accuracy improved from 54% to 99%. We estimate this coding sticker will improve our departmental remuneration by £67,938 per year.

Conclusion:

Rigid ureteroscopy, flexible uretero-renoscopy and ureteric stenting were initially poorly coded. The introduction of a simple operative coding sticker improved coding compliance to 99% and increased operative remuneration.

A Karnaugh map based approach towards systemic reviews and meta-analysis

Studying meta-analysis and systemic reviews since long had helped us conclude numerous parallel or conflicting studies. Existing studies are presented in tabulated forms which contain appropriate information for specific cases yet it is difficult to visualize. On meta-analysis of data, this can lead to absorption and subsumption errors henceforth having undesirable potential of consecutive misunderstandings in social and operational methodologies. The purpose of this study is to investigate an alternate forum for meta-data presentation that relies on humans’ strong pictorial perception capability. Analysis of big-data is assumed to be a complex and daunting task often reserved on the computational powers of machines yet there exist mapping tools which can analyze such data in a hand-handled manner. Data analysis on such scale can benefit from the use of statistical tools like Karnaugh maps where all studies can be put together on a graph based mapping. Such a formulation can lead to more control in observing patterns of research community and analyzing further for uncertainty and reliability metrics. We present a methodological process of converting a well-established study in Health care to its equaling binary representation followed by furnishing values on to a Karnaugh Map. The data used for the studies presented herein is from Burns et al (J Publ Health 34(1):138–148, 2011) consisting of retrospectively collected data sets from various studies on clinical coding data accuracy. Using a customized filtration process, a total of 25 studies were selected for review with no, partial, or complete knowledge of six independent variables thus forming 64 independent cells on a Karnaugh map. The study concluded that this pictorial graphing as expected had helped in simplifying the overview of meta-analysis and systemic reviews.

Integrated clinical coding in urology – a novel way of working

Objectives:

The objective of this article is to report a completed cycle of audit of coding co-morbidities for bladder outlet surgery. We also present a novel way of working to achieve better accuracy in capturing admitted patient care data and coding in urology.

Materials and methods:

We undertook a retrospective case note and coding review of all bladder outlet surgeries performed in a single month. After initiating several measures to improve data recording and capture, we re-audited our results prospectively and analysed the results.

Results:

The initial accuracy of coding co-morbidities was 73%. This improved to 100% at re-audit. However, we found that procedure coding errors remained. We have devised a novel working model to improve all coding issues related to urology.

Conclusion:

It is possible to improve accuracy of coding by educating clinicians working alongside our integrated model of a team of a clinician with an interest in coding with coding and finance personnel.

Financial impact of surgical training on hospital economics: an income analysis of 1184 out-patient clinic consultations

INTRODUCTION

In many countries healthcare commissioning bodies (state or insurance-based) reimburse hospitals for their activity. The costs associated with post-graduate clinical training as part of this are poorly understood. This study quantified the financial revenue generated by surgical trainees in the out-patient clinic setting.

METHODS

A retrospective analysis of surgical out-patient ambulatory care appointments under 6 full-time equivalent Consultants (Attendings) in one hospital over 2 months. Clinic attendance lists were generated from the Patient Access System. Appointments were categorised as: 'new', 'review' or 'procedure' as per the Department of Health Payment by Results (PbR) Outpatient Tariff (Outpatient Treatment Function Code 104; Outpatient Procedure Code OPRSI1).

RESULTS

During the study period 78 clinics offered 1184 appointments; 133 of these were not attended (11.2%). Of those attended 1029 had sufficient detail for analysis (98%). 261 (25.4%) patients were seen by a trainee. Applying PbR reimbursement criteria to these gave a projected annual income of £GBP 218,712 (€EU 266,527; $USD 353,657) generated by 6 surgical trainees (Residents). This is equivalent to approximately £GBP 36,452 (€EU 44,415; $USD 58,943) per trainee annually compared to £GBP 48,732 (€EU 59,378; $USD 78,800) per Consultant. This projected yearly income off-set 95% of the trainee's basic salary.

CONCLUSION

Surgical trainees generated a quarter of the out-patient clinic activity related income in this study, with each trainee producing three-quarters of that generated by a Consultant. This offers considerable commercial value to hospitals. Although this must offset productivity differences and overall running costs, training bodies should ensure hospitals offer an appropriate return. In a competitive market hospitals could be invited to compete for trainees, with preference given to those providing excellence in training.

Systematic review of discharge coding accuracy

INTRODUCTION

Routinely collected data sets are increasingly used for research, financial reimbursement and health service planning. High quality data are necessary for reliable analysis. This study aims to assess the published accuracy of routinely collected data sets in Great Britain.

METHODS

Systematic searches of the EMBASE, PUBMED, OVID and Cochrane databases were performed from 1989 to present using defined search terms. Included studies were those that compared routinely collected data sets with case or operative note review and those that compared routinely collected data with clinical registries.

RESULTS

Thirty-two studies were included. Twenty-five studies compared routinely collected data with case or operation notes. Seven studies compared routinely collected data with clinical registries. The overall median accuracy (routinely collected data sets versus case notes) was 83.2% (IQR: 67.3-92.1%). The median diagnostic accuracy was 80.3% (IQR: 63.3-94.1%) with a median procedure accuracy of 84.2% (IQR: 68.7-88.7%). There was considerable variation in accuracy rates between studies (50.5-97.8%). Since the 2002 introduction of Payment by Results, accuracy has improved in some respects, for example primary diagnoses accuracy has improved from 73.8% (IQR: 59.3-92.1%) to 96.0% (IQR: 89.3-96.3), P= 0.020.

CONCLUSION

Accuracy rates are improving. Current levels of reported accuracy suggest that routinely collected data are sufficiently robust to support their use for research and managerial decision-making.