Clinical coding (the translation of conditions/diseases into an alpha-numeric code) is performed by the Trust’s Clinical Coding Team, which is a part of the Information Governance Team. The data produced is an integral part of health information management and is used both nationally and locally for health research, public health programming, epidemiological (how disease spreads) studies and also allocation of funds. In acute hospitals, coding also helps facilitate a system known as Payment by Results (PbR) whereby a trust will get paid for the outcome of a patient’s stay. At present, this system is not used in mental health trusts.
The Team codes approximately 525 finished consultant episodes (FCEs – the time a patient spends in the care of one consultant in one health-care provider) per month and our aim is to be accurate as possible, to identify the primary diagnosis (the main condition treated during the episode), assign codes to all relevant conditions and ensure timely throughput of the coding.
As is the case across the NHS, the Clinical Coding Team is a small cog in a large machine which aims for the best possible outcome for its patients. Coding is reliant upon accurate and timely information being available in the patient’s care record, without which the coding will be neither accurate nor robust. This will have an adverse effect on the quality of the coding and subsequently the patient, as the data will be compromised.
The Trust’s Clinical Coding Lead is Kevin Harris, who can be contacted by emailing Kevin.Harris@merseycare.nhs.uk.