Clinical coding

What is clinical coding?

The role of a clinical coder is a vital one to the trust.The basic role is to translate the medical terminology from the patients’ casenotes into a coded format using the following tools:

• International Classification of Diseases (ICD - 10) and related health conditions (3 volumes) for diagnostic information (used internationally).
• Office of Population Censuses and Surveys (OPCS-4.5) for procedural codes (UK only use). 

Why use codes?

Originally coding was used for statistical purposes only and from as early as the mid 17th century people have been interested in collecting data on diseases.

View some early coding information
 
Coding has moved on since those early days and for a number of years  has played a large part in how funds are allocated to hospitals but 2009 saw a major change with the introduction of ‘payments by results’ (PBR). The coded data is vital to the running of this system. Other statistical areas of use are cost analysis, commissioning, aetiology studies, health trends, epidemiology studies, clinical indicators and casemix planning.

The codes are also used clinically in areas such as - clinical governance, clinical audit and outcome and effectiveness of patient's care and treatment. 

What do we collect?

• Primary diagnosis and any relevant secondary diagnoses or co-morbidities.
• Neoplasms, anatomical site and nature – plus Morphology – eg Squamous cell carcinoma of lung with metastases to pleura.
• Any poisonings – plus how they occurred.
• Any injuries – plus how they occurred – eg fall down a manhole.
• Primary procedure and any relevant secondary procedures - this could range from a blood transfusion to a hip replacement.
•  Any relevant site or laterality  - eg neck of femur, unilateral or bilateral operation. 

Our team

Accuracy is vital and coders have to attend an 18 day course initially then attend regular workshops and refresher courses to ensure their skills are updated. After two to three years the coder is expected to study for the National Clinical Coding Qualification (NCCQ), the exam consists of two papers of three hours each. If successful the coder becomes an Accredited Clinical Coder (ACC). We have three ACC’s in the
department so far.

More information

Clinical Coding Department
Undercroft
East Cheshire NHS Trust,
Victoria Road
Macclesfield
SK10 3BL