Clinical coding:

1. Clinical coding: should we be going back to the basics? “Perfection is not attainable, but if we chase perfection we can catch excellence” Vince Lombardi (American Football Coach) National Centre for Classification in Health, The University of Sydney Vera Dimitropoulos

2. Why do we code health data? Is there a primary focus? • Support quality patient care – is that it? • Health services planning and evaluation • Research • National morbidity statistics • Quality assurance activities • Epidemiology • ABF/casemix, diagnosis related groups (DRGs)

3. Back to Education Whoknows we may even learn something new or forgotten…. • Clinician education on classification principles and the importance of good clinical documentation needs to be embedded in university curricula • Primary benefit of good clinical documentation is to support quality patient care – flow on impact on appropriate AR-DRG • Good clinical documentation ensures continuity of care between providers – flow on impact on patient safety • Clinician understanding of the implications of good clinical documentation in relation to ABF will lead to high quality coded health data – flow on impact for appropriate recognition of hospital activity.

4. Shortfall in HIMs and Clinical Coders nationally What are we doing about the HIM and clinical coder shortfall? According to the Australian Institute of Health and Welfare report on the Australian Coder Workforce Shortfall (2010), there is a recognised shortfall in the Health Information Management and clinical coder workforce within Australia.

5. Back to rebuilding the HIM profession Going back to basics is a refresher course which can re-ignite our passion. • Re-establish university degrees in Health Information Management • La Trobe in Victoria – long standing • Curtin in Western Australia – long standing • QUT in Queensland – new (2013) • UWS in NSW – (HIM major in B.ICT degree) under development • Need to build the HIM profession in order to provide coding mentoring/training to new entry HIMs and clinical coders • NSW Clinical Coding Workforce Enhancement Project (HETI) • HIMAA and OTEN clinical coding distance education programs

6. Basic HIM principles in relation to clinical coding This is just a start! • Underpinning knowledge in medical science and medical terminology • Knowledge of all types of health classification systems (e.g. ICD, DRGs) • Data definitions • Coding standards • Forms/screen design for data capture • Data quality/coding auditing • Ensure channels of communication between HIM/coder and clinician(s) are open and frequently used

7. Clinical Coding

8. The importance of good clinical documentation FamPractManag. 2003 Oct;10(9):31-36.

9. The building blocks • ICD-10-AM and ACHI codes are the building blocks of AR-DRGs used in many settings as health care funding mechanisms. • The principal diagnosis, additional diagnoses and interventions, as documented in the clinical record, are converted into ICD-10-AM and ACHI codes. These codes are then used in the grouping process.

10. The Australian Coding Standards (ACS)

11. ACS 0002 – Additional diagnoses “A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted patient care, episode of residential care or attendance at a health care establishment, as represented by a code.” (METeOR: 391322 (Australian Institute of Health and Welfare 2012) For coding purposes, additional diagnoses should be interpreted as conditions that affect patient management in terms of requiring any of the following: • commencement, alteration or adjustment of therapeutic treatment • diagnostic procedures • increased clinical care and/or monitoring.

12. Recent changes to ACS 0401 Diabetes Mellitus and Intermediate Hyperglycaemia From 1 July 2012, Rule 1 within ACS 0401 overrides ACS 0002 Additional diagnoses “Diabetes Mellitus and Intermediate Hyperglycaemia should always be coded when documented “

13. Data comparability Implications for coding practices and public health research are to be expected when a version change in classification is implemented. Therefore: It is vital that researchers understand the impact of classification changes on morbidity data which is based on a subset of the population (acute inpatient episodes) Reference: Australian Bureau of Statistics (2000) Causes of Death (3303.0) 13

14. Data comparability continued Each revision of the ICD-10-AM has resulted in some lack of comparability over time for specific conditions e.g.: Diabetes mellitus has undergone extensive revision to include more detail about the disease process and how it should be coded Sleep disorders have been relocated from ICD-9-CM Chapter 16 (signs and symptoms) to Chapter 6 in ICD-10-AM (nervous) To analyse trends for any given condition, the condition needs to be tracked across ICD-10-AM revisions and through any categories or chapters in which it appears. 14

15. Data comparability continued

16. Data comparability continued

17. Don’t shortchange ourselves or patient care “The key is to document everything you do and code for what you document. ….You play a major role in caring for complex health problems. You deserve to also be paid appropriately” Hill E (2003) How to Get All the 99214s You Deserve.FamPractManag. 2003 Oct;10(9):31-36.