Aim: To investigate the magnitude of revenue lost by the Department of Trauma and Orthopaedics at Ports-mouth Hospitals NHS Trust in 2007 as a result of providing outpatient viscosupplementation joint injections.

Methods: Data was collated on all outpatient intra-articular hyaluronic acid viscosupplementation performed by our department in 2007. Information on existing HRG tariffs for orthopaedic outpatient attendances as well as clinical coding of joint injections by our department was also gathered.

Results: The 2007/2008 tariffs for orthopaedic outpatient first and follow-up appointments were £147 and £73 respectively for adults, and £157 and £85 respectively for children (under 17 years of age). No additional mandatory tariff currently exists for joint injections performed in the outpatient setting. During our study period, the cost of a dose of viscosuplementation (Hyaluronic acid 60mg/ 3 ml) varied between £213 and £248. A total of 812 doses of viscosupplementation were administered to outpatients by our department resulting in pharmaceutical costs of £175,126. Only 751 cases of outpatient appointment with joint injection (all types) were recorded and coded by the department.

Conclusions:

As long as no mandatory DoH tariff exists for out-patient joint injections, outpatient viscosupplementation remains an expensive service for trusts to provide and may warrant rationalisation.

Introduction

The Department of Health determined that, from April 2011, Trusts would not be paid for emergency readmissions within 30 days of discharge. The purpose of our project was to identify factors associated with such readmissions and implement plans for improvement.

Introduction. We conducted an audit on hip fractures to analyse the accuracy of coding and payment by results in our institution. Materials/Methods. The initial audits analysed hip fracture over a period of four months at two different trusts. Case notes were reviewed to extract data regarding diagnosis, comorbidities and operative procedures. The findings were compared with the data from clinical coding department and difference in the tariff was analysed. A re-audit was performed at Trust B after implementation of changes to assess improvement. Results. In the initial audit 111 patients were reviewed. Twenty-three percent patients had all data correctly coded. In the remaining 77%, some of the co-morbidities had been missed, e.g. UTI, anaemia and osteoporosis etc. 11.7% of operative procedures and 16.5% of fracture patterns were incorrectly coded resulting in loss of £53 000 over the 4 month period. Poor documentation and the use of ‘uncodable’ language by clinicians were responsible for missing co-morbidities, while inadequate medical knowledge of clinical coders resulted in the incorrect recording of operative procedures. We implemented changes in the form of clinical coders training, awareness of “codable words” by medical staff and writing the procedure codes by the surgeons themselves. A re-audit at Trust B showed an estimated savings of £18540.00 over 3 months period, demonstrating a significant improvement. Conclusion. Inaccuracies in clinical coding result in loss of tariff. Awareness of codable words, writing the operative codes by surgeons and training of clinical coders can improve clinical coding and payment by results in NHS hospitals

Introduction: Payment by results was introduced into the NHS in an effort to finance Trusts fairly and reward good performance. Tariffs for a single patient episode are derived from diagnosis and procedure codes, comorbidities, patient age, and length of stay. Poor data collection can result in a lower tariff with subsequent under billing of the Primary Care Trust (PCT). In addition, an individual surgeon’s performance in future comparison league tables will rely on the accuracy of this data. Methods of documentation and data collection vary in different units. We evaluated the methods and the resulting tariffs in 2 units in the Northern Deanery. Methods: Case notes were examined for 20 consecutive orthopaedic patients discharged from unit A, and 20 from unit B. The case mix in the two groups was similar. A correct tariff based on case notes was compared with the actual tariff used to bill the PCT for each patient. The coding department derived actual tariffs from data in electronic discharge summaries created by ward based junior medical staff in unit A. Accurately completed typed case notes were available to coders in unit B. Results: Only 3 of the 20 tariffs (15%) were correct for unit A patients. This represented a total financial loss to the trust of £14892 (25% of total revenue). In unit B, 19 of 20 (95%) tariffs were correct. An error in the coding for one procedure resulted in a higher tariff being assigned to a patient (total gain of £486, < 1%). Discussion: Orthopaedic departments create large Trust revenue. Accurate documentation and information transfer for coding is essential for payment by results to function correctly. Trusts which fail to do this will be financially penalised and surgeon league tables may not adequately reflect individual case complexity. We recommend all Trusts use the model established in unit B

We devised a four-part clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk estimation. We retrospectively reviewed a series of consecutive PTKRs performed by the senior author. A classification system was devised to take account of principal risk factors in PTKR (Table 1). The patients were grouped accordingly, and the following were compared:. Length of stay. Postoperative complications. Early post discharge follow-up assessment. Multiple regression analysis was performed. This revealed:. Similar complication rates in the NCP and CPI groups. 3-fold and 4-fold increase in the cumulative risk in the CPII, and CPIII groups respectively (p< 0.001). Increased length of stay in the CPIII group (p< 0.001). Conclusion: This classification correlates well with complication rates from surgery, and has a role in stratifying patients for preoperative planning and risk counselling. It is reproducible and can be used for larger patient groups via the National Joint Registry. Our findings also have implications for payment by results and fixed tariffs for PTKR

To assess concordance between hospital coding and clinician coding for patients undergoing spinal instrumentation procedures and determine if our coding systems result in accurate financial reimbursement from the primary care trust (PCT). We conducted a one year retrospective review of 41 patients who underwent spinal instrumentation procedures. Data collected from IT systems included: operation description, clinician procedure code, hospital procedure code, Hospital Health Resource grouping (HRG), clinician HRG, instrumentation costs and PCT reimbursement fees. From this data we compared coding based re-imbursement fees and actual surgical costs, taking into account exact instrumentation prices. In all cases the primary hospital and clinician coding values differed. Using the clinician code would have altered the HRG group in 16 patients. Using solely clinician coding would have generated less financial reimbursement than using hospital coding. In 23 patients undergoing complex spinal procedures, instrumentation costs represented a significant proportion of the final fee obtained from the PCT, thus leaving a small proportion for the associated hospital stay costs. This suggests instrumentation costs are inadequately reimbursed from the PCT. Hospital coding appears more accurate than clinician coding and results in greater financial reimbursement. On the whole, we found there to be insufficient reimbursement from the PCT. The variable and sometimes substantial cost of spinal instrumentation procedures results in inadequate reimbursement for many procedures. We feel the payment by results (PBR) scheme is suboptimal for such procedures and adequate reimbursement can only be achieved by direct billing on an individual case basis

Aims. To devise a simple clinical risk classification system for patients undergoing primary total knee arthroplasty (PTKR) to facilitate risk and cost estimation, and aid pre-operative planning. Methods. We retrospectively reviewed a series of consecutive PTKRs performed by the senior author. A classification system was devised to take account of principal risk factors in PTKR. Four groups were devised: 1) Non complex PTKR (CP0): no local or systemic complicating factors; 2) CPI: Locally complex: Severe or fixed deformity and/or bone loss, previous bony surgery or trauma, or ligamentous instability; 3) CPII Systemic complicating factors: Medical co-morbidity, steroid or immunosuppressant therapy, High BMI, (equivalent to ASA of III or more); 3) CPIII: Combination of local and systemic complicating factors (CPI+CPII). The patients were grouped accordingly and the following were compared: 1) length of stay, 2) post-operative complications, and 3) early post-discharge follow-up assessment. The complications were divided into local (wound problems, DVT, sepsis) and systemic (cardiopulmonary, metabolic, and systemic thromboembolic) complications. Results. The total number of patients was 119 (CP0=37,CPI=19,CPII=30,CPIII=33). Multiple regression analysis revealed: 1) no significant difference between complication rates in the CP0 and CPI groups, 2) 3-fold and 4-fold increase in the cumulative risk in the CPII and CPIII groups respectively (p<0.001), 3) significantly increased length of stay in the CPII and CPIII groups (p<0.001). Conclusion. The groups in this classification system correlate well with complication rates from surgery. As such this system has a role in stratifying patients for pre-operative planning and risk counselling. It is reproducible and can be used for larger patient groups via the National Joint Registry. Our findings also have implications for payment by results and fixed tariffs for PTKR, as the higher complication rates in the CPII and CPIII groups are likely to attract greater expense by hospitals in the course of these patients' treatment

Introduction: Since the introduction of payment by results in the NHS in 2004, the accurate recording of services performed has played a crucial role in reimbursement to hospital trusts by primary care trusts (PCT). Failure to accurately charge for these services causes a shortfall in funding received. Under the new reimbursement system, similar treatments are grouped together under the same tariff and referred to as a Healthcare Resource Group (HRG). Coding is the assignment of procedures to HRG’s. We aim to assess the accuracy of coding performed at our institution and link this directly to the funds received from the PCT. Foot and ankle surgery has a particular interest in coding due to the multiple codes that are utilised to code for one procedure. Method: We looked at 40 consecutive operations performed at our institution. We compared the codes assigned by the surgeon placing the patient on the waiting list, which were the codes seen directly on the operating list with the final codes given to the PCT. We compared the two codes and looked at the difference in final costing. Results: There were a total of 75 codes from the 40 operations assigned by the surgeon compared with 103 codes assigned by the coding staff. Although most of the codes were different when the final costing data was generated there was little difference in the overall costs. Discussion: The importance of accurate coding has become paramount in the current national health service funding. We have shown large discrepancies between the codes the surgeon produces and the final code given to the PCT. Although, in our unit, this has not led to differing final reimbursement figures, it does have the potential to create inaccuracies with a failure to pay for work performed. We will present our data and describe the correct coding for common procedures in foot and ankle surgery, to allow accurate reimbursement

Introduction: To train the surgeon adds to the length of procedures and this is currently not accounted for, in the finance received to perform the operation by the hospital. Objective: Our study focussed on these main questions:. What is the effect on the length of a procedure when a trainee is involved?. What is the effect on the length of a list and the number of procedures performed on the list when a trainee is involved?. What percentage of cases had trainee involvement for anaesthetics and surgery?. Is this is statistically significant?. Method: Data was taken from two different sources, firstly, the ORMIS theatre system and patient operation notes. These were used to determine the length of six different types of orthopaedic procedures and the level of the main surgeon. This was collected in Stepping Hill hospital, Stockport, United Kingdom between June and July 2008. The second source used was a consultant’s logbook comprising 227 primary total knee replacements between 2004 and 2008. Results: The data collected via the ORMIS system produced trends suggesting trainees took longer to perform procedures than consultants. The data from the consultant logbook statistically proved this. List times appeared unaffected by trainee presence. In Orthopaedic surgeries, 92% times trainees were present during the procedure and out of this 17% cases were performed by trainees. For total hip replacements done by trainees the procedure took significantly longer surgical time than consultant performed procedures (p = 0.0337). Among these cases, 71% were performed by senior trainees. The consultant’s log book data also suggested the similar trends. In all comparisions, time taken by trainees to perform surgeries were statistically significant. Trainee performed with consultant scrubbed versus consultant performed (P = < 0.0001), trainee performed with consultant in theatre versus consultant performed(P = 0.0318) and trainee performed with consultant scrubbed versus trainee performed with consultant in theatre (P = 0.002). Discussion and Conclusion: Hospitals are paid a fixed fees per operation due to introduction of payment by results system as they are paid a fixed tariff for a particular procedure. Training increases the length of a procedure and therefore in an efficient structured environment prevents as many cases being done on a list. Therefore, training future surgeons costs the hospital money. To counter this, training hospitals should be given financial incentives to train in surgery, or procedures performed by trainees should be priced differently to account for the time lost by training