Clinical Coding Audit: No coding – No Income – No Hospital

Abstract

Aim Audit assessing the accuracy of clinical coding by trust guidance on revenue generation. Method Clinical coding form containing common clinical codes placed at the front of patient notes between July 2014 and August 2014 on a respiratory ward. Medical staff, preferably registrars or consultants, recorded the primary diagnoses and comorbidities on the form. Completed forms sent to the clinical-coding department who supplied the tariff generated. Revenue generated during the test period was compared with the prior two months. Results Comparable discharges between periods with average revenue generated a difference per patient of £339, totalling a £36,273 increase per month. Conclusion Simple diagnoses and comorbidities coding forms completed by a senior doctor helped junior doctors improve documentation and accuracy at discharge whilst generating more revenue for the trust.