First seen in Independent Practitioner Today
In the last of his three-part series on clinical coding, Peter Connor investigates treatment codes and how they set a benchmark.
Independent practitioners may not have had much exposure to diagnosis coding, but treatment codes are different. Every time specialists or hospitals submit an electronic bill to a private medical (PMI), it is the treatment code on the invoice which determines what they wil be paid for.
Clearly, treatment codes are important financially, but that is not all. In this article, I will look at the additional role that clinical codes will play in producing statistics which help demonstrate quality and outcomes within the private sector; a task which has become even more important in the light of the Competition Commission's investigation into the private health market.
Private sector treatment codes
When submitting invoices for surgical procedures, independent practitioners and hospitals refer to the schedule of procedures and fees provided by the PMI concerned for the appropriate code. These codes are taken from a code set developed by five major PMIs under the banner of the Clinical Coding and Schedule Development Group (CCSD)1 which was launched in 2006. The PMIs decide which CCSD codes to include in their schedules. A brief explanation of the CCSD system, and that used in the NHS (OPCS), see 'Character Analysis: Private and NHS Treatment and Procedure Codes Compared'.
Practitioners are generally only expected to select a single code encompassing the component parts included in a single procedure. But a single code does not necessarily tell us much about the procedure that was carried out. CCSD codes will not generally reveal the approach taken (whether an operation was carried out laparoscopically, for example) or the exact site of the procedure (left or right knee, level of the spine etc). By contrast, the OPCS system used in the NHS supports the use of multiple codes to describe one procedure: the main code, site code and approach code (see 'An example of treatment coding') which captures useful information for the hospital episode statistics.
Unlike OPCS, CCSD purely focuses on procedures and does not cover non-procedural activities such as outpatients’ appointments, pathology, pharmacology and radiology. For this, independent practitioners generally use the Industry Standard Charge Codes developed by Healthcode and we are in the process of further developing the standard which applies to drug and prosthetic services.
Points of comparison
At this point, independent practitioners might be wondering why they should concern themselves with procedure codes, beyond using them correctly when submitting invoices. However, there is another factor which may prompt the private sector to pay more attention to coding standards: the pressure for greater transparency about quality and outcomes across the healthcare sector.
The NHS has long published a range of anonymised information about the care provided by different organisations, including ISTCs, on the Hospital Episode Statistics (HES) website (www.hesonline.nhs.uk). This is only possible because of the treatment and diagnosis codes assigned to particular episodes of care by the NHS’s clinical coding teams in a format which is suitable for data processing and analysis. From these codes, HES provides data about most types of patient care and treatment, from inpatient and outpatient care, to maternity care and critical care. It also reports Patient Reported Outcome Measures (PROMs), the results of questionnaires sent to patients before and after NHS-funded unilateral hip and knee replacements, groin hernia and varicose vein surgeries.
But there was, until now, no equivalent scheme for the private sector, promoting criticism from the Office of Fair Trading which identified the “lack of easily comparable information available to patients and their GPs on the quality and costs of private healthcare services” as an area of concern when referring the private healthcare market to the Competition Commission2.
Comparing private hospitals
As regular readers of Independent Practitioner Today will know, the Private Healthcare Information Network (PHIN) is spearheading a project to address these concerns which is supported by the Independent Health Advisory Service (IHAS) and the main hospital groups, including Ramsay (see 'Independent Perspectives'). PHIN plans to publish the first Private Hospital Episode Statistics in early 2013, covering quality indicators for hospital admissions, re-admissions treatment and discharge. The plan is to supplement this with other measures such as PROMs at a later date and it is likely that the project will extend to information about individual consultants in due course.
As in the NHS, the source for these statistics will be the procedure codes generated by the hospitals which are mapped by Healthcode into the equivalent OPCS codes used by the public sector. The intention is to make quality in private healthcare as directly comparable to the indicators used in the NHS as possible, so that patients and GPs in Britain can understand the services provided. However, true comparability will not be possible unless the private and public sectors adopt the same coding standards.
To return (briefly) to a theme in my previous article, diagnosis coding is another critical element in providing meaningful quality and outcomes data. Diagnosis codes allow the statistical data to be adjusted to reflect the challenges involved in episodes of care. For example, they may reveal that a private hospital which carries out thousands of hip replacements each year is most cost-effective and quickest option for patients without co-morbidities but might not necessarily be as suitable for a patient with complex care needs. However, as I explained in my previous article, the version of ICD-9 diagnosis codes used by the private sector has significant limitations compared to the ICD-10 system used in the NHS and I urge hospitals and private insurers to address this inconsistency.
Speaking in code
Independent practitioners may be forgiven for being put off by the sight of letters and numbers rather than the medical terminology they are used to – after all, they are not trained clinical coders. And nor should they have to be with sufficient tools and support. For example, Healthcode enables users to look up the correct procedure and diagnosis codes through a user-friendly text-based search. We can also translate the ICD-9 and CCSD codes with which independent practitioners might be more familiar into their ICD-10 and OPCS equivalents.
However, I do think it is important to have an appreciation of clinical codes: their use in compiling health statistics; in billing; and in demonstrating quality and outcomes. What’s more, their full potential has not yet been explored. For example, when episodes of healthcare are coded, it should be easier for doctors to collate anonymised information for their own clinical audits which could be used as supporting information for appraisal and revalidation.
In short, codes are the information currency in today’s health service. Every independent practitioner needs to recognise their value.
Character analysis: private and NHS treatment and procedure codes compared
The CCSD classification system used in the private sector is set out over 20 chapters which generally correspond to an anatomical site or treatment. For example, Chapter 15: skin and subcutaneous tissue. Users can then search the subcategories within the chapter such as 15.1 ‘lesions of skin’ for a list of relevant 5-character alphanumeric codes and descriptions eg S0608 ‘sentinel lymph node biopsy for melanoma’
There are just over 2000 CCSD codes but only one should be needed in most cases which should reflect the entire procedure, including elements such as anaesthesia and post-operative care. The CCSD has produced five coding principles to guide users of the code set which warn about the use of combined codes and states that ‘Where two codes are commonly used together, a new combined code should be requested’.
The OPCS-4 system developed and used by the NHS includes more than 6,000 alphanumeric 3 or 4-character codes. The first character is always a letter which corresponds to one of the 24 code chapters in the OPCS classification. These are anatomically based, for example Chapter A (the nervous system) or Chapter S (skin). However, Chapters Y and Z cover Subsidiary Classification of Methods of Operation and Subsidiary Classification of Sites of Operation respectively so that extra detail can be added where this is not part of the main code. There is no Chapter I or O although ‘O’ codes have been used to increase capacity in other chapters).
The initial letter of the code is followed by two numbers to create a 3-character group code eg J04 ‘repair of liver’. Where more specific information is available, the HES website explains that clinical coders use a 4-character code with a decimal point separating the group code from the fourth character eg J04.2 ‘repair of laceration of liver’In contrast to the CCSD system, coders are expected to provide separate codes where necessary to reflect the complexity of the procedure as well as the part of the body (including laterality) and the approach eg laparoscopic.
An example of treatment coding
A 40-year-old man presented to a consultant orthopaedic surgeon several weeks after straining his left knee during a cricket match. The surgeon referred him to the hospital for further investigation and treatment if necessary.
A subsequent arthroscopy revealed the patient had sustained a bucket handle tear of the posterior medial meniscus and the surgeon performed an arthroscopic medial menisectomy and washout.
Private sector CCSD code:
W8200 Arthroscopic meniscectomy (including debridement)
Public sector OPCS codes:
W82.2 Endoscopic resection of semilunar cartilage NEC
Z94.3 Left-sided operation
Independent perspectives
Sally Taber, Director at the Independent Healthcare Advisory Service:
“IHAS believes that clinical coding is becoming increasingly important for private healthcare because it provides the means to compare the quality and outcome of treatments, both within the sector and with the NHS.”
“There will be an ever-greater emphasis on benchmarking treatment across both sectors. For example, supported by the IHAS, the Private Healthcare Information Network (PHIN) is now collating anonymised coding data from over 150 private sector hospitals which will soon be published in the form of the first Independent Hospital Episode Statistics, using the same coding language as the NHS.”
“The next challenge is diagnosis coding, as it is currently rare for hospitals and practitioners to record diagnosis codes for private patients. Diagnosis coding makes quality and outcome data far more meaningful, as well as enabling more accurate case-mix adjustment, and the recording of non-surgical treatment looks very bare without it. We believe that in order to remain competitive and be able to communicate the true value of private healthcare, we will need to find cost-effective ways to ensure accurate diagnostic coding in the very near future.”
The view from a major private provider:
Jane Cameron, Director of Clinical Services, Ramsay Health Care
“Ramsay are committed to submitting coded data as part of the PHIN project to publish private hospital episode statistics and we feel that there is a willingness throughout the private sector to share this data so that costs and treatment outcomes can be compared.”
References:
1 The Clinical Coding and Schedule Development Group http://www.ccsd.org.uk/
2 OFT refers private healthcare market to the Competition Commission, OFT, 4 April 2012 http://www.oft.gov.uk/news-and-updates/press/2012/26-12