User:Little pob/Clinical coding

Clinical coding, also medical coding and diagnostic coding, is the process of assigning diagnosis, procedural, pharmaceutical, and/or topographical codes to an episode of health care.

It can be carried out by clinical staff who has received training in clinical coding, but is more often performed by specialized health informatics staff called clinical coders.

Medical coding, as an integrated part of the electronic health information systems, is used to improve the quality and effectiveness of medical services.

Coding in practice

The basic task of the coder is to classify medical and health care concepts using a standardized classification. Most aspects of health care and outcomes can be coded; inpatient, outpatient episodes, general practitioner visits, population health studies and mortality events can all be coded.

The process of clinical coding can be simplified to three basic phases: abstraction, assignment, and review. The training of clinical coding practicioners may split these slightly differently in other counties.

Abstraction

The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation notes. When an episode of care is being coded by a clinical coder, rather than a member of medical staff, for example; they are looking for clear indication of the diagnoses, comorbidities and any interventions or procedures.

Assignment

The assignment phase has two parts: finding the appropriate code(s) from the classification for the abstraction; and entering the code into the system being used to collect the coded data.

Review

Reviewing the code set produced from the assignment phase is very important. Clinical coder must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility." By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mix mechanism, the clinical coder will also review the diagnosis-related group to ensure that it does fairly represent the health encounter.

What is clinical coding?

Clinical coding is the translation of written, scanned and/or electronic clinical documentation about patient care into code format. For example, hypertension is represented by the code 'I10'; general anaethesia is represented by the code'92514-XX[1910]'.

A standardised classification system, The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), is applied in all Australian acute health facilities. It is based on the World Health Organisation (WHO) ICD-10 system, updated with the Australian Classification of Health Interventions (ACHI), Australian Coding Standards (ACS). Clinical coding is a specialised skill requiring excellent knowledge of medical terminology and disease processes, attention to detail, and analytical skills.

What is coded data used for?

The assigned codes and other patient data are processed by grouper software to determine a diagnosis-related group (DRG) for the episode of care, which is used for funding and reimbursement. This process allows hospital episodes to be grouped into meaningful categories, helping us to better match patient needs to health care resources.

Weaknesses in Diagnostic Coding

Generally coding is a concept of modeling reality with reduced effort but with physical copying.

• Hence the result of coding is a reduction to the scope of representation as far as possible to be depicted with the chosen modeling technology. There will be never an escape, but choosing more than one model to serve more than one purpose. That led to various code derivatives, all of them using one basic reference code for ordering as e.g. with ICD-10 coding. However, concurrent depiction of several models in one image remains principally impossible.

• Focusing a code on one purpose lets other purposes unsatisfied. This has to be taken into account when advertising for any coding concept. The operability of coding is generally bound to purpose. Inter-referring must be subject of evolutionary development, as code structures are subject of frequent change.

• Unambiguous coding requires strict restriction to hierarchical tree structures possibly enhanced with multiple links, but no parallel branching for contemporary coding whilst maintaining bijectivity.

• Spatial depictions of n-dimensional code spaces as coding scheme trees on flat screens may enhance imagination, but still leave the dimensionality of image limited to intelligibility of sketching, mostly as a 3D object on a 2D screen. Pivoting such image does not solve the intelligibility problem.

• Projections of code spaces as flattened graphs may ease the depiction of a code, but generally reduce the contained information with the flattening. There is no explanation given with many of the codes for transforming from one code system to another. That leads to specialized usage and to limitations in communication between codes. The escape is with code reference structures (as e.g. not existing with SNOMED3).

• Hierarchical ordering of more than one code system may be seen as appropriate, as the human body is principally invariant to coding. But the dependency implied with such hierarchies decrease the cross referencing between the code levels down to unintelligibility. The escape is with hyper maps that exceed planar views (as e.g. with SNOMED3) and their referring to other codes (as e.g. yet not existing with SNOMED3).

• Purpose of documenting will be seen as essential just for the validation of a code system in aspects of correctness. However this purpose is timely subordinate to the generating of the respective information. Hence some code system shall support the process of medical diagnosis and of medical treatment of any kind. Escape is with a specialised coding for the processes of working on diagnosis as on working with treatment (as e.g. not intended with SNOMED3).

• Intelligibility of results of coding is achieved by semantic design principles and with ontologies to support navigating in the codes. One major aspect despite the fuzziness of language is the bijectivity of coding. Escape is with explaining the code structure to avoid misinterpreting and various codes for the very same condition (as e.g. yet not served at all with SNOMED3).