Abstract
Introduction: Accurate & ethical coding is challenging and directly impacts on Payment by Results (PbR). The objectives were to review the existing pattern of coding for lumbar spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical comorbidities and post-op complications.
Methods: A retrospective review of 100 consecutive lumbar spine surgeries operated from Apr2006–Jan2007 was conducted. The coding excel sheet, hospital notes and laboratory reports were reviewed.
Results: The primary procedural accuracy was 96%, however this reduced to 79% for the entire description of performed surgery. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Spinal fusion codes were omitted and revision cases were coded as primary surgeries in 2 instances each. Surgical levels were coded incorrectly in 12 and harvest of iliac crest bone graft omitted in 4 cases respectively. Medical comorbidities were coded appropriately in 70%. The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 62.5% of the cases(5/8).
Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but also for data quality, audit and research. The financial implications regarding PbR governed by Healthcare Resource Group (HRG) codes (dictated by Official population and census surveys [OPCS4.4] & International classification of diseases [ICD–10] codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders & clinicians.
Correspondence should be addressed to SBPR at the Royal College of Surgeons, 35–43 Lincoln’s Inn Fields, London WC2A 3PE, England.
