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Does senior clinical input to clinical coding influence Healthcare Resource Group (HRG) allocation in acute children's services?

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Payment by Results (PbR) is replacing block contracts to finance clinical services. Admissions are allocated to Healthcare Resource Groups (HRGs) from diagnosis and procedure codes. Clinicians may have limited input to this. Incomplete coding might lead to under-funding of children's services. The aim of this project was to determine whether senior clinical input altered allocated clinical codes, HRGs and the financial consequences of this intervention.

A systematic sample of medical admissions to our children's wards (CW), Special Care Baby Unit (SCBU) and Neonatal Intensive Care Unit (NICU) in 2004 was selected. Each admission or case had been previously coded from discharge proforma by coding clerks. Cases were then re-examined by senior clinicians meeting with a clinical coding manager, using the case notes. Where appropriate, revised length of stay, primary and secondary diagnosis and procedure codes were allocated. If these were different to the original codes, the revised data were sent for re-grouping into HRGs. If the HRG was different, the data were submitted to the finance department for PbR costing of the original and revised data.

During 2004 there were 3109 CW and 254 neonatal admissions to our department. A sample of 148 episodes was examined (106 CW, 32 SCBU, 10 NICU). Overall, codes were revised in 50% (74/148) of cases and 46% (34/74) of these resulted in different HRGs. Primary diagnosis code was revised in 22% of CW, 50% of SCBU and 20% of NICU episodes. Secondary diagnosis code changed in 26% of CW, 78% of SCBU and 40% of NICU episodes. Revised primary diagnosis code alone determined a change in HRG (P < 0.0001 by logistic regression). Currently, PbR tariff is only applicable to HRGs from CW activity; for these the revised HRG altered the tariff in 18% (19/106) episodes. The resultant financial reimbursement for these 19 cases would give a net gain of £71/case. Extrapolating this to a full year of CW activity would increase income by £39 713, a modest increase to the annual departmental budget (∼0.7%).

Clinical input to diagnostic coding had a substantial effect on HRGs. However, under PbR, this would have only a modest financial benefit in our department. Direct clinical coding by senior paediatric medical staff was not cost-effective, but simple, minimal cost measures could increase the completeness and accuracy of clinical coding.


Document Type: Regular Paper

Publication date: May 1, 2006

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