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Clinical Coding Audit
Assignment Report 2013/14 Hywel Dda University Health Board
Clinical Coding Report
2013/14
Hywel Dda University Health Board
Contents
1 Executive summary ..................................................................................... 1
2 Introduction ................................................................................................... 2
3 Background .................................................................................................... 3
4 Scope & objective ....................................................................................... 4
5 Policy & process .......................................................................................... 5
6 Coding accuracy ........................................................................................... 6
6.1 Diagnoses ................................................................................................................ 6
6.1.1 Primary diagnoses ...................................................................................................... 7
6.1.2 Secondary diagnoses ................................................................................................. 8
6.2 Surgical procedures/interventions ............................................................. 10
6.2.1 Primary procedure/intervention ......................................................................... 11
6.2.2 Secondary procedure/intervention ................................................................... 12
6.3 Other coding issues .......................................................................................... 13
6.4 Payment analysis ................................................................................................ 15
Appendix A: Detailed coding assessment
Appendix B: Recommendations
Appendix C: Site analysis
Appendix D: Audit approach
Appendix E: Glossary of coding error codes
Appendix F: Assurance and risk definitions
Appendix G: Report data
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1. Executive Summary
It is apparent from our work that the overall accuracy of clinical coding is of mixed
quality with performance level that would only meet level one of Information
Governance Toolkit (IG) Requirement 505 (NB. The Health Board is not required to
submit IG Toolkit levels, and this is used purely as a means of benchmarking). The
coding of the primary diagnosis was very good, but the accuracy of primary procedure
fell 2.42% short of level two standards. The accuracy of the clinical coding is shown
below:
CODING FIELD PERCENTAGE
CORRECT
IG REQ 505
LEVEL 2
IG REQ 505
LEVEL 3
Primary diagnosis 92.86% 90% 95%
Secondary diagnosis 84.88% 80% 90%
Primary procedure 87.58% 90% 95%
Secondary procedure 83.33% 80% 90%
Good practice was noted in relation to the support the clinical coding function
receives across the Health Board, with dedicated time provided for training, as well as
the funding of a clinical coding auditor.
While there are there are a number of opportunities to improve processes which will
further improve accuracy as described within Appendix A, as a result of our findings
the assurance level which we are able to provide in respect of clinical coding and
underlying processes is:
SIGNIFICANT ASSURANCE
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2. Introduction
Accurate data quality and clinical coding are imperative to support patient care and
to ensure the information is used for improving healthcare as well as contributing to
effective management.
To provide consistently recorded data, well-defined standards must be applied to
allow comparisons to be made across time and between sources. The NHS uses the
International Statistical Classifications of Diseases and Related Health Problems, Tenth
Revision (ICD-10) and the Office Population Censuses and Surveys of Surgical
Operations and Procedures, Fourth Revision (OPCS-4) as the standards for diagnostic
and procedural coding. The data may be derived from Clinical Terms (the Read
codes). The classifications provide the framework, using rules and conventions that,
when applied accurately result in the provision of high quality, statistically meaningful
data.
Although Wales are not required to submit audit results for Information Governance
(IG) purposes the Health Board decided that they would find benefit in following the
guidelines as set out by IG Toolkit Requirement 505. IG Toolkit Version 11.0 was
launched in April 2013 and, within that framework, requirement 505 states that trusts
should have:-
established documented procedures for the regular audit of clinical coding;
carried out an internal clinical coding audit programme within the last twelve
months which was based on the requirements and standards within the latest
version of NHS Clinical Coding Audit Methodology and must have been
undertaken by staff on the registered list of clinical coding auditors; and,
where required, had an external clinical coding audit commissioned by the
Audit Commission.
This report provides an appraisal on the current position of Hywel Dda University
Health Board in adhering to national clinical coding standards. The audit was based
on the methodology detailed in the NHS Clinical Coding Audit Methodology Version
7.0.
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3. Background
The Health Board deals with approximately 112,211 finished consultant episodes
(FCEs) per year, which are all coded by the clinical coding staff using ICD-10 and
OPCS-4 to generate clinical information of inpatient activity. This is broken down
across site as follows:
Site Finished consultant episodes
Glangwili General Hospital 41,775
Prince Philip Hospital 19,450
Withybush General Hospital 32,230
Bronglais General Hospital 18,756
The coders, who are part of a centralised Clinical Coding Department within Planning
and Performance, are responsible for the entire coding process, from abstraction
through to input.
There are 21.01 whole time equivalent (WTE) clinical coders, inclusive of the Clinical
Coding Manager and Supervisors. The clinical coding function across the four sites is
made up from 25 coding staff, 10 of whom are accredited clinical coders (ACCs). The
Clinical Coding Manager has responsibility across the four sites; there are Supervisors
at two of the sites; the Health Board also employs a registered Clinical Coding Auditor,
who assisted with the audit.
The Health Board works to a formula for staffing levels of 6,600 FCEs per WTE. On
the surface the current staffing is working to 5,340 FCEs per WTE, but the Clinical
Coding Manager, Supervisors and Auditor do not have a full clinical coding workload
to account for their other responsibilities.
The source document used for the extraction of clinical coding data at the Health
Board is the case note, supported by a discharge summary and proforma.
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4. Scope & objective
To measure the quality of the clinical coding within the Health Board and to assist in
improving the quality of clinical coding the objectives of the audit were:-
To assess how well the coded data accurately reflects the diagnosis and
procedures described in the clinical records;
To focus on cardiology and general surgery with a portion of the sample
covering miscellaneous specialties;
To benchmark the accuracy against standards set out Information Governance
Toolkit Requirement 505;
To determine if the coding team thoroughly reviews appropriate source
documents;
To report errors in clinical coding assignments;
To identify sources of clinical coding errors and make recommendations for
correction;
To identify any clinical coding training requirements;
To determine the quality of the source documentation for the clinical
coding function;
To promote interchange between clinician and coder to improve the quality
of coded data; and
To further promote interaction with the Information Department, Finance
Department and other function leads.
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5. Policy & process
The Department has a Policy and Procedure document in place that is well structured,
and supports the management and provision of information to all of the clinical
coders via a shared drive. The document was last reviewed and updated in October
2013 and remains current.
The Health Board uses the Medicode encoder; one issue relating to this is the re-
sequencing of procedure codes when they are transferred from Medicode into the
Myrddin Patient Administration System.
The clinicians actively engage in the clinical coding process through various avenues.
In Withybush General Hospital the clinicians validate the main diagnosis, and partially
validate other diagnoses and procedures against the discharge letter. Elsewhere, the
Clinical Coding Manager liaises with senior clinicians in the Health Board who have
clinical roles in Informatics. Also the coders have access to clinicians to query clinical
information and to ask advice about conditions and procedures.
The Department has a programme of data quality accuracy checks that incorporate
clinical coding; audits are performed monthly, if there are no staffing issues.
The last external audit was carried out in 2010.
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6. Coding accuracy
6.1. Diagnoses
Diagnostic information is required for the recording of both primary and secondary
diagnoses for each episode of care. The definition of a primary diagnosis is:
"The first diagnosis field(s) of the coded clinical record (the primary
diagnosis) will contain the main condition treated or investigated during
the relevant episode of healthcare.
Where a definitive diagnosis has not been made by the responsible
consultant the main symptom, abnormal finding or problem should be
recorded in the first diagnosis field of the coded clinical record"1.
Therefore, on discharge the patient should be assigned a primary diagnosis even if a
definitive diagnosis is not available. In addition to the primary diagnosis, all relevant
secondary diagnoses should be recorded on the discharge front sheet. Secondary
diagnoses should include:
Conditions or problems dealt with during the episode of care
Conditions, which pre-exist in the patient
Patient status e.g. dependence on dialysis, etc.
The secondary diagnoses should be recorded in order to accurately reflect the care
received by the patient.
1 NHS Executive Health Service Guidelines HSG (96) 23 20 September 1996
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6.1.1. Primary diagnoses
Of the 252 episodes audited 234 (92.86%) primary diagnoses were coded correctly
with errors categorised as depicted and detailed below.
Figure 1 – Primary diagnosis coding analysis and error types
The agreed errors that were identified in the audit comprised of:
Non-coder errors (errors that are outside of the coders control and related to the
documentation provided or a procedure in place)
i. On one (0.40%) occasion the primary diagnosis was incorrect due to
information being available to the auditor that was not available at the time
of coding (PDI).
Coder errors
ii. One (0.40%) primary diagnosis was incorrect at three-character level (PD3).
iii. On four (2.78%) occasions the primary diagnosis was incorrect at fourth
character level (PD4).
iv. On two (0.79%) occasions the condition the auditor deemed to be the
primary diagnosis had been recorded by the coder but not sequenced in the
primary position (PDIS).
v. There were seven (2.78%) omitted primary diagnoses noted by the auditor
(PDO).
234
1
17
Primary diagnoses
Correct
Non-coder error
Coder error
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6.1.2. Secondary diagnoses
It is important that all relevant secondary diagnoses are recorded accurately in order
to reflect the care provided to the patient during the relevant episode of care.
Secondary diagnoses recorded should include additional conditions and
complications arising during an episode of care, and pre-existing conditions, which
require the continuing care of the patient during their episode of care.
Of the 853 valid secondary diagnoses 724 (84.88%) were coded correctly with errors
categorised as depicted and detailed below.
Figure 2 - Secondary diagnosis coding analysis and error types
The agreed errors that were identified in the audit comprised of:
Non-coder errors
vi. Eight (0.94%) secondary diagnoses were incorrect due to information being
available to the auditor that was not available at the time of coding (SDI).
Coder errors
vii. Eight (0.94%) secondary diagnoses were incorrect at three-character level
(SD3).
viii. On 16 (1.88%) occasions the secondary diagnosis was incorrect at fourth
character level (SD4).
ix. On 94 (11.02%) occasions a secondary diagnoses was omitted (SDO).
724
8 142
Secondary diagnosis
Correct
Non-coder error
Coder error
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x. There were 18 unnecessary secondary diagnosis codes assigned (SDNR).
xi. One (0.12%) external cause code was recorded incorrectly (ECI).
xii. Two (0.23%) external cause codes had been omitted (ECO).
xiii. Three unnecessary external cause codes had been recorded (ECNR).
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6.2. Surgical procedures/interventions
Information regarding surgical procedures / interventions undertaken is required for
every relevant episode of patient care, and should be documented on the discharge
front sheet by the clinical staff responsible for the patient.
According to OPCS-4.62, the definition of an intervention is: "...those aspects of clinical
care carried out on patients undergoing treatment:-
for the prevention, diagnosis, care or relief of disease;
for the correction of deformity or deficit, including those performed for cosmetic
reasons;
associated with pregnancy, childbirth or contraceptive or procreative
management.
Typically this will be:
surgical in nature; and/or
carries a procedural risk; and/or
carries an anaesthetic risk; and/or
requires specialist training; and/or
requires special facilities or equipment only available in an acute care setting”
It is generally considered that the procedure / intervention of most relevance should
be selected as the primary procedure i.e. the main surgical operation in terms of
complexity and use of resources.
Secondary procedures / interventions are considered to include supplementary
procedures / interventions such as diagnostic procedures or which are less complex
than the main procedure.
2 OPCS Classification of Interventions and Procedures Version 4.6, TSO page viii
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6.2.1. Primary procedure/intervention
Of the 161 valid primary procedures 141 (87.58%) were coded correctly with errors
categorised as depicted and detailed below.
Figure 3 - Primary procedure coding analysis and error types
The agreed errors that were identified in the audit comprised of:
Coder errors
xiv. Three (1.86%) primary procedures were incorrect at three-character level
(PP3).
xv. Four (2.48%) primary procedures were incorrect at fourth character level
(PP4).
xvi. On two (1.24%) occasions the primary procedure described by the auditor
had been recorded but not sequenced in the primary position (PPIS).
xvii. On 11 (6.83%) occasions the primary procedure was omitted (PPO).
xviii. Two unnecessary primary procedures had been recorded (PPNR).
141
1 22
Primary procedure
Correct
Non-coder error
Coder error
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6.2.2. Secondary procedure/intervention
Of the 312 valid primary procedures 260 (83.33%) were coded correctly with errors
categorised as depicted and detailed below.
Figure 4 - Secondary procedure coding analysis and error types
The agreed errors that were identified in the audit comprised of:
Non-coder errors
xix. One (0.32%) secondary procedure was incorrect due to information being
available to the auditor that was not available at the time of coding (SPI).
Coder errors
xx. Five (1.60%) secondary procedures were incorrect at three-character level
(SP3).
xxi. On 11 (3.53%) occasions the secondary procedure was incorrect at fourth
character level (SP4).
xxii. One (0.32%) secondary procedure had been sequenced in a way that
contravened a national clinical coding standard (SPIS).
xxiii. On 34 (10.90%) occasions a secondary procedure code had been omitted
(SPO).
xxiv. 10 unnecessary secondary procedure codes had been recorded (SPNR).
260
161
Secondary procedure
Correct
Non-coder error
Coder error
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6.3. Other coding issues
The Health Board performed to a mixed standard on audit, and from such a
generalised audit the only concerns highlighted were:
The auditors found a large number of omitted secondary diagnoses; contributing the
more than any other error type found in the audit. These were all relevant to the
episode of care with many relating to a national standard or classification rule.
Information on endoscopy reports was occasionally misinterpreted, with incidental
findings recorded as the primary diagnosis rather than the reason for the
investigation, for example, a person investigated for weight loss having haemorrhoids
being coded as the primary diagnosis when the report stated that this was not the
cause. There were other occasions noted when incidental findings were not recorded.
A standard3 was introduced to clarify the use of fifth characters in Chapter XIII
Disorders of the musculoskeletal system and connective tissue. This states that their
use is “mandatory where the data is present in the medical record, and where doing
so adds more specific information”. A fifth character of ‘9’ was regularly assigned
when the site of involvement was not known, but this is not deemed necessary.
Medicode does bring up a command to assign a fifth character, but this can be
bypassed by the coder.
There were occasions when a diagnosis of ‘left ventricular systolic dysfunction’ (or
‘LVSD’ as it is abbreviated) was coded to I50.1 Left ventricular failure. The term itself
cannot be trailed and the diagnosis is not uniformly accepted as a heart failure, and
thus without a local policy to support it cannot be coded as such.
The documentation relating to haemorrhoids was poor and never specified whether
they were internal or external. The terminology used described the haemorrhoids by
degree and position; information found supported that this related to haemorrhoids
but there are no standards or local policies to support this.
The recording of anaesthetics was regularly omitted or coded as unspecified when a
specified type was documented, particularly Midazolam. It is a Welsh standard to
record anaesthetics and a local policy to record Midazolam to Y84.8 Other
anaesthetic, other specified.
3 ‘National Clinical Coding Standards ICD-10 4th Edition (2013)’ reference book – XIII-1
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It is a national clinical coding standard4 to record transthoracic echocardiograms (TTE)
whenever they are performed on inpatient episodes. It further confirms that a clinical
statement of ‘echocardiogram’ or ‘echo’ without further specification is coded to
U20.1 Transthoracic echocardiogram. TTEs being omitted from the coding record
across all sites made up 10 of the omitted procedures.
There were a number of occasions when angiocardiography procedures were coded
with Y53.4 Approach to organ under fluoroscopic control assigned in a supplementary
position without the method being specified in the medical record. There was no
local policy employed for this, and as such should have been coded to Y53.9
Unspecified approach to organ under image control.
There were a number of occasions when Y79.3 Transluminal approach to organ
through femoral artery was assigned to supplement a code for an angiocardiography.
There is no standard to state that this should not be coded but the guidance in the
OPCS-4.6 Instruction Manual5 indicates that this category is only intended to be
assigned for transcatheter aortic valve implantation (TAVI) procedures.
4 OPCS-4.6 Clinical Coding Instruction Manual – U-15 5 OPCS-4.6 Clinical Coding Instruction Manual – Y-23
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6.4. Payment analysis
Payment Pre-
audit
Payment Post-
audit
Gross financial
change
Net Financial
change
Number of
episode UTAs
£283,611 £290,011 £9,428 £6,400 17
These figures are based on the English Payment by Results system that processes
funding through the tariff attached to Healthcare Resource Groupings. This
information is used purely as an indication of the impact of the clinical coding
and not related to the funding that Hywel Dda University Health Board received.
The data is comparative and may not be fully compliant with all requirements
of the Payment by Results mechanism.
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A p p e n d i x | A.1
Appendix A: Detailed coding assessment
Ref Record
ID
Diagnosis Health
Board
code
Audit
Code
Diagnosis Error
Type
Rationale Financial
implication
Primary diagnoses
i 191315 Cystocele N811 N814 Uterovaginal prolapse,
unspecified
PDI Coded from urodynamics sheet only. Other
documentation stated that the patient had a
uterine prolapse.
£0
ii 191315 Gastroenteritis and
colitis of unspecified
origin
A099 A080 Rotaviral enteritis PD3 Stool sample came back as rotavirus four
days post discharge, which the coders would
have had access to.
£0
iii 189925 Left ventricular failure I501 I500 Congestive heart failure PD4 States that the patient has "biventricular
failure", which trails to I50.0.
£0
iv 191169 Unspecified acute lower
respiratory infection
J22X J440 Chronic obstructive
pulmonary disease with
acute lower respiratory
infection
PDIS The patient had COPD and a chest infection,
which is linked to J44.0 and does not require
the J22.X, in accordance with the national
standards.
-£187
Chronic obstructive
pulmonary disease with
acute lower respiratory
infection
J440 - --- SDNR
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Ref Record
ID
Diagnosis Health
Board
code
Audit
Code
Diagnosis Error
Type
Rationale Financial
implication
v 192249 Chronic obstructive
pulmonary disease,
unspecified
J449 K219 Gastro-oesophageal
reflux disease without
oesophagitis
PDO The patient was admitted for an OGD due to
reflux disease, which had not been coded.
£0
Secondary diagnoses
vi 189847 --- - I209 Angina pectoris,
unspecified
SDI The patient was having an angio-
cardiography because of worsening angina.
This was not mentioned on the
angiocardiography form, and the coders
don't have access to notes for these
investigations.
£0
vii 192433
Aortic valve disorder,
unspecified
I359 I080 Disorders of both mitral
and aortic valves
SD3 Patient has aortic and mitral regurgitation,
which was documented in the notes but not
reflected in the coding.
£0
viii 192361 Left ventricular failure I501 I518 Other ill-defined heart
diseases
SD4 Left ventricular failure was never confirmed,
only left ventricular systolic dysfunction. The
Health Board does not have a policy to code
this diagnosis in such a way.
£0
ix 192401 --- - Z539 Procedure not carried
out, unspecified reason
SDO The patient was admitted for a direct current
cardioversion, but this was cancelled.
-£722
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Ref Record
ID
Diagnosis Health
Board
code
Audit
Code
Diagnosis Error
Type
Rationale Financial
implication
x 189881 Other aortic valve
disorders
I358 - --- SDNR Aortic sclerosis was noted on echo-
cardiogram, but this was not carried out until
the next episode.
£0
xi 191226 Intentional self-
poisoning by and
exposure to
antiepileptic, sedative-
hypnotic,
antiparkinsonism and
psychotropic drugs, not
elsewhere classified -
Home
X610 X619 Intentional self-
poisoning by and
exposure to
antiepileptic, sedative-
hypnotic,
antiparkinsonism and
psychotropic drugs, not
elsewhere classified -
Unspecified place
ECI The medical record does not state where
overdose took place.
£0
xii 191214 Hypo-osmolality and
hyponatraemia
E871 E222 Syndrome of
inappropriate secretion
of antidiuretic hormone
SD3 The hyponatraemia was due to SIADH, which
was secondary to sertraline.
£0
--- - Y492 Drugs, medicaments
and biological
substances causing
adverse effects in
therapeutic use - Other
and unspecified
antidepressants
ECO
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Ref Record
ID
Diagnosis Health
Board
code
Audit
Code
Diagnosis Error
Type
Rationale Financial
implication
xiii 192287 Drowning and
submersion while in
swimming-pool - Sports
and athletics area
W673 - --- ECNR The external cause code had been
unnecessarily repeated.
£0
Primary procedure/intervention
xiv 191196 Diagnostic fibreoptic
endoscopic examination
of upper gastro-
intestinal tract -
Unspecified
G459 G448 Other therapeutic
fibreoptic endoscopic
operations on upper
gastrointestinal tract -
Other specified
PP3 The scope was used to unblock the stent,
which is a form of therapeutic procedure and
should have been reflected as such in the
coding.
£0
xv 189772 Diagnostic fibreoptic
endoscopic examination
of upper
gastrointestinal tract -
Unspecified
G459 G451 Fibreoptic endoscopic
examination of upper
gastrointestinal tract
and biopsy of lesion of
upper gastrointestinal
tract
PP4 It stated on the endoscopy sheet that they
took a cold biopsy from duodenum, which
was not reflected in the primary procedure
code.
+£79
xvi 191215 Excision or biopsy of
axillary lymph node
T873 B274 Total mastectomy NEC PPIS There is an issue with Medicode, which
altered the sequence of the procedure codes
into chronological order. The coder can
change them back, but they had not on this
occasion.
+£592
Total mastectomy NEC B274 T873 Excision or biopsy of
axillary lymph node
-
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Ref Record
ID
Diagnosis Health
Board
code
Audit
Code
Diagnosis Error
Type
Rationale Financial
implication
xvii 191158 --- - U201 Transthoracic
echocardiography
PPO The patient had an echocardiogram, which
must be recorded in accordance with national
clinical coding standards, but had not been.
£0
xviii 192401 Direct current
cardioversion
X501 - --- PPNR The patient was admitted for a DC
cardioversion, but this was cancelled.
£0
Secondary procedure/intervention
xix 189929 --- - Y829 Local anaesthetic -
Unspecified
SPI Anaesthetic not specified on documentation
used by the coder.
£0
xx 189942 Rubber band ligation of
haemorrhoid
H524 L703 Ligation of artery NEC SP3 The patient underwent a haemorrhoidal
artery ligation operation (HALO) procedure,
which has a national standard that must be
adhered to, which had not been on this
occasion.
£0
xxi 189873 Approach to organ
under fluoroscopic
control
Y534 Y539 Approach to organ
under image control -
Unspecified
SP4 Method of image control was not specified as
fluoroscopic.
£0
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Ref Record
ID
Diagnosis Health
Board
code
Audit
Code
Diagnosis Error
Type
Rationale Financial
implication
xxii
191194 Computed tomography
NEC
U212 U212 Computed tomography
NEC
All of the codes for the CT scan were
recorded, but there is a precise sequencing
standard that states that the Y98 must follow
the Y97 code.
£0
Radiology with post-
contrast
Y973 Y973 Radiology with post-
contrast
Chest NEC Z924 Y983 Radiology of three body
areas (or twenty–forty
minutes)
SPIS
Radiology of three body
areas (or twenty–forty
minutes)
Y983 Z924 Chest NEC
Abdomen NEC Z926 Z926 Abdomen NEC
Pelvis NEC O161 O161 Pelvis NEC
xxiii 190022 --- - Y84.8 Other anaesthetic -
Other specified
SPO The coding of anaesthetic is a national
standard, and the Health Board have a policy
to record sedation with specified drugs,
which had not been omitted.
£0
xxiv 190063 Creation of temporary
ileostomy
G742 G751 Refashioning of
ileostomy
PP3 The ileostomy was stated to have been
'revised’ and 'refashioned'; the lead term
refashioning is indexable and would cover the
creation of a new ileostomy and the revision
of the original ileostomy.
£0
Closure of ileostomy G753 - --- SPNR
Revisional operations
NOC
Y713 - --- SPNR
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Appendix B: Recommendations
1. Training
Issue Identified – There were a number of issues identified during the audit relating to the
interpretation of the information contained in the medical record and/or the national
standard that relate to it. The particular areas that were routinely identified by the auditors
were:
Co-morbidities were regularly omitted from the coding. This related to conditions that
impacted on the patient’s healthcare, and regularly to classification standards. Omitted
co-morbidities were the most common error type identified.
Endoscopy reports were often misinterpreted, with the primary diagnosis recorded by
the coder often being an incidental finding and not the reason for the investigation. In
addition the adherence to national standards relating to endoscopies was not always
followed.
The omission of transthoracic echocardiograms when they were clearly documented in
the medical record; this issue was identified at all sites;
The coding of anaesthetics is a standard in Wales, and must be coded when it is
documented; as well as this there is a local policy for the coding of Midazolam. These
were regularly omitted.
Risk Rating – Medium
Recommendation – The Health Board should conduct a series of short training sessions over
the following weeks to ensure that issues highlighted on audit are addressed with the clinical
coders. This will provide a forum for coders to consolidate their understanding and ask
questions to clarify the standards.
This should be followed up with internal audit one to two months later on the areas
addressed to ensure that these sessions have improved the quality of the clinical coding.
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2. Utilisation of in-house auditor
Issue Identified – The Health Board has supported the training of an in-house Clinical Coding
Auditor. The requirements of maintaining an auditor registration means that a significant
amount of their time needs to be spent on coding tasks. The Health Board to this point have
continued to support this by providing time to carry out these tasks. The support of this role
should support the continued improvement of the data quality of the coding function.
Risk Rating – Medium
Recommendation – The Health Board should continue to support the in-house Clinical
Coding Auditor’s utilisation. Over time this could be increased to incorporate working with
directorates and clinicians to identify areas where the coding and information provided to
support it could be improved. This in turn will lead to increased awareness and respect for
the function and promote a general desire to support each function in producing quality
information.
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3. Discuss Medicode issues with system developer
Issue Identified – There were a number of occasions when the auditors found errors in the
sequence of procedures, which meant the most resource intensive procedure was sequenced
in a secondary position. This was particularly the case with diagnostic procedures being
sequenced in a primary position ahead of therapeutic. On discussion it would appear this is
a known issue with the Medicode encoder, which re-sequences procedure codes into
chronological order when transferred to the Myrddin Patient Administration System. The
coders can alter the sequence on Myrddin but this is a waste of resource, as well as there
being potential to forget to do it.
Risk Rating – Medium
Recommendation – The Health Board should discuss the issue with 3M, the suppliers of
Medicode, at the earliest opportunity and ask for a patch to be written to prevent this issue
from continuing.
In the interim the Clinical Coding Manager should highlight this finding to the clinical coders
and ask them to be vigilant in ensuring that, before finalisation, the procedure codes are
sequenced in the correct position.
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4. Local policy
Issue Identified – There were a number of occasions when the clinical coding was coded to
a more specific code than what was documented in the medical record. This indicated that
the coders were aware of the method used for particular procedures but this was not
supported in the record or through the use of local policies. This was particularly relevant
for angiocardiography procedures that were consistently coded with a supplementary code
to reflect it was carried out under fluoroscopic image guidance.
It was also noted by the auditors that the quality of information provided for care of
haemorrhoids was poor. The detail was often limited and used terminology that cannot be
reflected in the clinical coding without the use of local policies.
Risk Rating – Low
Recommendation – The Clinical Coding Manager should discuss these and any other
applicable areas with the relevant clinicians and/or directorates to ensure that local policies
can be implemented, where needed, to improve the quality of the clinical coding.
These local policies should be implemented as soon as possible to avoid them being flagged
as errors in future audits. In addition they should have set review dates to ensure they
continue to reflect current practice and be signed off as understood by all relevant clinical
coders.
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5. Query the use of Y79
Issue Identified – The auditors noted that Y79.3 Transluminal approach to organ through
femoral artery was assigned in supplementary position following a code for an
angiocardiography. There is no standard to state that this should not be coded but the
guidance in the OPCS-4.6 Instruction Manual indicates that this category is only intended to
be assigned for transcatheter aortic valve implantation (TAVI) procedures.
Risk Rating – Low
Recommendation – The Health Board should send a query to the Welsh Standards Service
Desk to establish whether there is a requirement to assign the Y79.3 code following this
procedure or whether this is superfluous to the record. The resolution will then dictate
whether they should continue to assign the code in this way or to omit it in the future.
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Appendix C: Site analysis
Prince Philip Hospital
Primary diagnoses
Number of episodes Number correct Percentage
53 49 92.45
Coder Error Number Percentage
PD4 2 3.77
PDO 2 3.77
Secondary diagnoses
Number of valid
diagnoses
Number correct Percentage
207 185 89.37
Non-coder Error Number Percentage
SDI 6 2.90
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Coder Error Number Percentage
SD3 3 1.45
SD4 3 1.45
SDO 10 4.83
SDNR 7 -
Primary procedure/intervention
Number of episodes Number correct Percentage
37 37 100.00
Secondary procedure/intervention
Number of episodes Number correct Percentage
78 69 88.46
Non-coder Error Number Percentage
SPI 1 1.28
Coder Error Number Percentage
SP3 1 1.28
SP4 2 2.56
SPO 5 6.41
Glangwili General Hospital
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Primary diagnoses
Number of episodes Number correct Percentage
73 66 90.41
Coder Error Number Percentage
PD3 1 1.37
PD4 2 2.74
PDIS 1 1.37
PDO 3 4.11
Secondary diagnoses
Number of episodes Number correct Percentage
234 187 79.91
Non-coder Error Number Percentage
SDI 1 0.43
Coder Error Number Percentage
SD3 2 0.85
SDO 44 18.80
SDNR 5 -
Primary procedure/intervention
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Number of episodes Number correct Percentage
50 42 84.00
Coder Error Number Percentage
PP3 1 2.00
PP4 2 4.00
PPIS 1 2.00
PPO 4 8.00
Secondary procedure/intervention
Number of episodes Number correct Percentage
98 78 79.59
Coder Error Number Percentage
SP3 3 3.06
SP4 6 6.12
SPO 11 11.22
SPNR 5 -
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Withybush General Hospital
Primary diagnoses
Number of episodes Number correct Percentage
76 70 92.11
Non-coder Error Number Percentage
PDI 1 1.32
Coder Error Number Percentage
PD4 3 3.95
PDIS 1 1.32
PDO 1 1.32
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Secondary diagnoses
Number of episodes Number correct Percentage
167 131 78.44
Non-coder Error Number Percentage
SDI 1 0.60
Coder Error Number Percentage
SD3 1 0.60
SD4 4 2.40
SDO 27 16.17
SDNR 2 -
ECI 1 0.60
ECO 2 1.20
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Primary procedure/intervention
Number of episodes Number correct Percentage
49 42 85.71
Coder Error Number Percentage
PP3 1 2.04
PP4 2 4.08
PPIS 1 2.04
PPO 3 6.12
PPNR 1 -
Secondary procedure/intervention
Number of episodes Number correct Percentage
99 82 82.83
Coder Error Number Percentage
SP3 1 1.01
SP4 2 2.02
SPIS 1 1.01
SPO 13 13.13
SPNR 3 -
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Bronglais General Hospital
Primary diagnoses
Number of episodes Number correct Percentage
50 49 98.00
Coder Error Number Percentage
PDO 1 2.00
Secondary diagnoses
Number of episodes Number correct Percentage
236 212 89.83
Coder Error Number Percentage
SD3 2 0.85
SD4 9 3.81
SDO 13 5.51
SDNR 4 -
ECNR 3 -
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Primary procedure/intervention
Number of episodes Number correct Percentage
26 21 80.77
Coder Error Number Percentage
PP3 1 3.85
PPO 4 15.38
PPNR 1 -
Secondary procedure/intervention
Number of episodes Number correct Percentage
37 31 83.78
Coder Error Number Percentage
SP4 1 2.70
SPO 5 13.51
SPNR 2 -
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Appendix D: Audit approach
The audit was based on the NHS Clinical Coding Audit Methodology Version 7.0 and the Code
of Best Practice for Clinical Coding Auditors. The documents provide guidance on conducting
a clinical coding audit.
Codes on CDS were considered accurate if they described the actual condition of the patient
(and any procedures performed) as completely as possible within the constraints of the
classifications used.
The three dimensions of the coding accuracy are:
Individual codes: are they an accurate reflection of the clinical statement?
Totality of codes: do they represent all the relevant clinical details?
Sequencing of codes: are the codes in the correct sequence as defined by
the rules and conventions of the classification, and the mandated definition
of a primary diagnosis?
Coding errors were then evaluated as follows:
- Incorrect main diagnosis selected
- Incorrect three character category
- Incorrect fourth character category
- Omission of diagnosis / procedure codes
- Unnecessary codes
- Incorrect sequencing of diagnostic / procedure codes
Accurate coded information is essential for many areas of accountability in the NHS.
Information derived from clinical coding is used in many areas at secondary and primary care,
strategic health authority and national level to analyse performance and levels of achievement,
to support the government's national initiatives to improve service quality and deliverance
through Payment by Results, clinical indicators and clinical governance.
However, all information for coding purposes is derived from the information provided by the
clinical staff responsible for the patient. It is therefore essential that all information recorded
in the patient’s medical record be documented clearly, accurately and completely.
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The audit did not concentrate solely on the accuracy of the coding, but also on other factors
influencing the coding process. Without studying the wider picture of how information is
created for coding purposes, one cannot expect to attain a realistic picture of the factors that
determine the accuracy of coding.
Other areas studied during the audit included:
Documentation issues:
Document incomplete
Documentation inconsistent, unclear
Terminology unclear
Information regarding the episode not available in the
clinical records
Lack of clear procedures for coding and abstraction
Lack of procedures for reviewing clinical records
Coded to consultant specification (resulting in a contravention of a
coding rule/convention or standard)
The error keys used were based on those outlined in NHS Clinical Coding Audit
Methodology Version 7.0 (Appendix D).
The auditors documented any discrepancies found using the appropriate audit worksheets. A
first draft of the audit report including findings, conclusions and recommendations of the
audit was submitted to the Health Board for review.
The auditors also checked the accuracy of a subset of key data items for Admitted Patient
Care. These were:
Start date (episode)
End date (episode)
Secondary diagnosis (ICD)
Primary procedure (OPCS)
Procedure date (primary)
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Appendix E: Glossary of coding error codes
Unsafe to Audit Error Key
UTA UNSAFE TO AUDIT
The auditor is unable to audit the coded clinical data against the source documentation.
For example, there is insufficient or no information regarding the episode in the auditor’s
source documentation.
Primary Diagnosis Error Key
Coder Error
PD3 PRIMARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL
The primary diagnosis code has been allocated to an incorrect three character.
PD4 PRIMARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL
The primary diagnosis code has been allocated to an incorrect fourth character.
PD5 PRIMARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL
The primary diagnosis code has been allocated to an incorrect fifth character.
PDIS PRIMARY DIAGNOSIS INCORRECTLY SEQUENCED
The primary diagnosis code recorded by the auditor has not been sequenced by the coder
as the primary diagnosis.
PDO PRIMARY DIAGNOSIS OMITTED
The primary diagnosis recorded by the auditor has not been recorded by the coder in any
diagnosis field.
Non-Coder Error
PDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF
CODING
Information available to the auditors was not available at the time of coding. This is where
information regarding the episode became available after the episode was coded. This
error key is not to be used if the information was not accessed by the clinical coder at the
point of coding, for example, with histopathology reports.
This error key would also be assigned by the auditor when the source documentation used
at the time of coding did not contain all pertinent information required for accurate and
complete coding and the coder did not have access to this information, for example,
coding from pro-forma with no access to the casenotes.
PDD PRIMARY DIAGNOSIS DOCUMENTATION ISSUE
The auditor is unable to code the clinical data from the source documentation and
compare against that of the Health Board’s due to unclear or inconsistent information.
For example:
Inconsistency between information recorded by clinical staff contained on the source
documentation and it is not clear which is correct
The source documentation is illegible.
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PDM PRIMARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION
There is a clear and documented directive from management to contravene coding to
national standards.
For example:
by unbundling diagnoses or procedures into component parts
by adding or optimising the coded clinical data to alter the derived HRG.
PDC PRIMARY DIAGNOSIS CODED TO CONSULTANT SPECIFICATION
There is a clear and documented directive from clinicians to contravene coding to national
standards or capture those instances where a clinician has requested that coding be done
in a particular way as it more accurately captures a diagnosis.
For example, by unbundling diagnoses or procedures into component parts.
PDSC PRIMARY DIAGNOSIS INCORRECT DUE TO SYSTEM CONSTRAINT
Due to the system that the Organisation uses the primary diagnosis code is technically
incorrect at some level, omitted or sequenced incorrectly.
Secondary Diagnosis Error Key
Coder Error
SD3 SECONDARY DIAGNOSIS INCORRECT AT THREE CHARACTER LEVEL
The secondary diagnosis code has been allocated to an incorrect three character.
SD4 SECONDARY DIAGNOSIS INCORRECT AT FOUR CHARACTER LEVEL
The secondary diagnosis code has been allocated to an incorrect fourth character.
SD5 SECONDARY DIAGNOSIS INCORRECT AT FIVE CHARACTER LEVEL
The secondary diagnosis code has been allocated to an incorrect fifth character.
SDNR SECONDARY DIAGNOSIS NOT RELEVANT
The secondary diagnosis recorded by the coder is not relevant to the episode of care.
SDO SECONDARY DIAGNOSIS OMITTED
The secondary diagnosis has been recorded by the auditor as relevant but is missing from
the Organisation’s recorded episode.
SDIS SECONDARY DIAGNOSIS INCORRECT SEQUENCING
The sequence of the secondary diagnosis codes contravenes national standards. This error
key can only be assigned for error in the following national standards:
1. Outcome of delivery (Z37 and Z38 if not well baby)
2. Asterisk codes must be preceded by a dagger code
3. Specific coding conventions in ICD-10 i.e. use additional code
4. Extent of body surface in burns (T31, T32).
ECI EXTERNAL CAUSE CODE INCORRECT
The external cause code recorded by the Organisation is incorrect at any character level.
ECO EXTERNAL CAUSE CODE OMITTED
The external cause code has been omitted from the Organisation’s recorded episode.
ECNR EXTERNAL CAUSE CODE NOT RELEVANT
The external cause code recorded by the coder is not relevant to the episode of care.
Non-Coder Error
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SDI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF
CODING
Information available to the auditors was not available at the time of coding. This is where
information regarding the episode became available after the episode was coded. This
error key is not to be used if the information was not accessed by the clinical coder at the
point of coding, for example, with histopathology reports.
This error key would also be assigned by the auditor when the source documentation used
at the time of coding did not contain all pertinent information required for accurate and
complete coding and the coder did not have access to this information, for example,
coding from pro-forma with no access to the casenotes.
SDD SECONDARY DIAGNOSIS DOCUMENTATION ISSUE
The auditor is unable to code the clinical data from the source documentation and
compare against that of the Health Board’s due to unclear or inconsistent information.
For example:
Inconsistency between information recorded by clinical staff contained on the source
documentation and it is not clear which is correct
The source documentation is illegible.
SDM SECONDARY DIAGNOSIS CODED TO MANAGEMENT SPECIFICATION
There is a clear and documented directive from management to contravene coding to
national standards.
For example:
by unbundling diagnoses or procedures into component parts
by adding or optimising the coded clinical data to alter the derived HRG.
SDC SECONDARY DIAGNOSIS CODED TO CONSULTANT SPECIFICATION
There is a clear and documented directive from clinicians to contravene coding to national
standards or capture those instances where a clinician has requested that coding be done
in a particular way as it more accurately captures a diagnosis.
For example, by unbundling diagnoses or procedures into component parts.
SDSC SECONDARY DIAGNOSIS INCORRECT DUE TO SYSTEM CONSTRAINT
Due to the system that the Organisation uses the secondary diagnosis code is technically
incorrect at some level, omitted or sequenced incorrectly.
Primary Procedure Error Key
Coder Error
PP3 PRIMARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL
The primary procedure code has been allocated to an incorrect three character.
PP4 PRIMARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL
The primary procedure code has been allocated to an incorrect fourth character.
PPIS PRIMARY PROCEDURE INCORRECTLY SEQUENCED
The primary procedure code recorded by the auditor has not been sequenced by the coder
as the primary procedure.
PPO PRIMARY PROCEDURE OMITTED
The primary procedure recorded by the auditor has not been recorded by the coder in any
procedure field.
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PPNR PRIMARY PROCEDURE NOT RELEVANT
The primary procedure recorded by the coder is not relevant to the episode of care.
Non-Coder Error
PPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF
CODING
Information available to the auditors was not available at the time of coding. This is where
information regarding the episode became available after the episode was coded. This
error key is not to be used if the information was not accessed by the clinical coder at the
point of coding, for example, with histopathology reports.
This error key would also be assigned by the auditor when the source documentation used
at the time of coding did not contain all pertinent information required for accurate and
complete coding and the coder did not have access to this information, for example,
coding from pro-forma with no access to the casenotes.
PPD PRIMARY PROCEDURE DOCUMENTATION ISSUE
The auditor is unable to code the clinical data from the source documentation and
compare against that of the Health Board’s due to unclear or inconsistent information.
For example:
Inconsistency between information recorded by clinical staff contained on the source
documentation and it is not clear which is correct
The source documentation is illegible.
PPM PRIMARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION
There is a clear and documented directive from management to contravene coding to
national standards.
For example:
by unbundling diagnoses or procedures into component parts
by adding or optimising the coded clinical data to alter the derived HRG.
PPC PRIMARY PROCEDURE CODED TO CONSULTANT SPECIFICATION
There is a clear and documented directive from clinicians to contravene coding to national
standards or capture those instances where a clinician has requested that coding be done
in a particular way as it more accurately captures a diagnosis.
For example, by unbundling diagnoses or procedures into component parts.
PPSC PRIMARY PROCEDURE INCORRECT DUE TO SYSTEM CONSTRAINT
Due to the system that the Organisation uses the primary procedure code is technically
incorrect at some level, omitted or sequenced incorrectly.
Secondary Procedure Error Key
Coder Error
SP3 SECONDARY PROCEDURE INCORRECT AT THREE CHARACTER LEVEL
The secondary procedure code has been allocated to an incorrect three character.
SP4 SECONDARY PROCEDURE INCORRECT AT FOUR CHARACTER LEVEL
The secondary procedure code has been allocated to an incorrect fourth character.
SPIS SECONDARY PROCEDURE INCORRECTLY SEQUENCED
The Organisation has not sequenced the procedure coding according to the rules and
conventions of the classification.
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SPO SECONDARY PROCEDURE OMITTED
The secondary procedure recorded by the auditor as relevant but is missing from the
Organisation’s recorded episode.
SPNR SECONDARY PROCEDURE NOT RELEVANT
The secondary procedure recorded by the coder is not relevant to the episode of care.
Non-Coder Error
SPI INFORMATION AVAILABLE AT THE TIME OF AUDIT NOT AVAILABLE AT THE TIME OF
CODING
Information available to the auditors was not available at the time of coding. This is where
information regarding the episode became available after the episode was coded. This
error key is not to be used if the information was not accessed by the clinical coder at the
point of coding, for example, with histopathology reports.
This error key would also be assigned by the auditor when the source documentation used
at the time of coding did not contain all pertinent information required for accurate and
complete coding and the coder did not have access to this information, for example,
coding from pro-forma with no access to the casenotes.
SPD SECONDARY PROCEDURE DOCUMENTATION ISSUE
The auditor is unable to code the clinical data from the source documentation and
compare against that of the Health Board’s due to unclear or inconsistent information.
For example:
Inconsistency between information recorded by clinical staff contained on the source
documentation and it is not clear which is correct.
The source documentation is illegible.
SPM SECONDARY PROCEDURE CODED TO MANAGEMENT SPECIFICATION
There is a clear and documented directive from management to contravene coding to
national standards.
For example:
by unbundling diagnoses or procedures into component parts
by adding or optimising the coded clinical data to alter the derived HRG.
SPC SECONDARY PROCEDURE CODED TO CONSULTANT SPECIFICATION
There is a clear and documented directive from clinicians to contravene coding to national
standards or capture those instances where a clinician has requested that coding be done
in a particular way as it more accurately captures a diagnosis.
For example, by unbundling diagnoses or procedures into component parts.
SPSC SECONDARY PROCEDURE INCORRECT DUE TO SYSTEM CONSTRAINT
Due to the system that the Organisation uses the secondary procedure code is technically
incorrect at some level, omitted or sequenced incorrectly.
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Appendix F: Assurance Definitions and Risk Classifications
Level of
Assurance Description
High
Our work found some low impact control weaknesses which, if addressed would improve
overall control. However, these weaknesses do not affect key controls and are unlikely to
impair the achievement of the objectives of the system. Therefore we can conclude that the
key controls have been adequately designed and are operating effectively to deliver the
objectives of the system, function or process.
Significant There are some weaknesses in the design and/or operation of controls which could impair
the achievement of the objectives of the system, function or process. However, either their
impact would be minimal or they would be unlikely to occur.
Limited There are weaknesses in the design and / or operation of controls which could have a
significant impact on the achievement of the key system, function or process objectives but
should not have a significant impact on the achievement of organisational objectives.
No There are weaknesses in the design and/or operation of controls which [in aggregate] have
a significant impact on the achievement of key system, function or process objectives and
may put at risk the achievement of organisational objectives.
Risk Rating Assessment Rationale
Critical Control weakness that could have a significant impact upon, not only the system, function
or process objectives but also the achievement of the organisation’s objectives in relation
to:
the efficient and effective use of resources.
the safeguarding of assets.
the preparation of reliable financial and operational information.
compliance with laws and regulations.
High Control weakness that has or is likely to have a significant impact upon the achievement of
key system, function or process objectives.
This weakness, whilst high impact for the system, function or process does not have a
significant impact on the achievement of the overall organisation objectives.
Medium Control weakness that:
has a low impact on the achievement of the key system, function or process
objectives;
has exposed the system, function or process to a key risk, however the likelihood
of this risk occurring is low.
Low Control weakness that does not impact upon the achievement of key system, function or
process objectives; however implementation of the recommendation would improve overall
control.
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Appendix G: Report Data
Distribution
Name Title Distribution
A Tracey Interim Associate Director of Informatics PDF
D Croft Interim Head of Information PDF
K O'Doherty Clinical Coding Service Manager PDF
Draft issued to/responses received from
Name Title Date
K O'Doherty Clinical Coding Audit Assignment Report 2013/14 19.02.14
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Review prepared on behalf of MIAA by
Name: Gary Bagley (ACC)
Title: Clinical Coding Academy Manager
Telephone: 0151 285 4522
Email: gary.bagley@miaa.nhs.uk
Name: Katherine Harrison (ACC)
Title: Senior Clinical Coder/ Approved Clinical Coding Auditor
Telephone: 01267 227093
Email: Katherine.Harrison@wales.nhs.uk
Name: Tony Cobain
Title: Head of IM&T Assurance
Telephone: 0151 285 4510
Email: tony.cobain@miaa.nhs.uk
Acknowledgement and further information
MIAA would like to thank all staff for their co-operation and assistance in completing this
review.
This report has been prepared as commissioned by the organisation, and is for your sole use.
If you have any queries regarding this review please contact Gary Bagley.
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