Clinical codes are commonly used by independent practices for billing as well as recording clinical events, but making sense of all those letters and numbers can feel like trying to master a foreign language.
Healthcode coding analyst Jess Donelan offers practical advice and looks at the wider potential of coding in the sector. He also explains how Healthcode is using its expertise to make the world of codes accessible for all.
Unless you are a techie, you are unlikely to spend much time thinking about codes and yet the truth is that they underpin our daily lives.
In our age of technology, all our digital information is recorded in alphanumeric codes so it can be easily processed by organisations, from HM Revenue and Customs to membership organisations and retailers.
This is particularly relevant to the healthcare sector where it is necessary to collect masses of information about patients, morbidity and treatments to track the progress of disease and make timely and informed decisions about matters such as resource allocation.
Clinical coding allows this vital data to be recorded in a standard format so it can be analysed in seconds by computer and shared with other healthcare providers.
In the independent healthcare sector, clinical coding has not been embraced as it has in the NHS, but this is changing.
Here are the main types of clinical codes you are likely to come across as an independent practitioner, and their uses:
First produced by the World Health Organisation (WHO) in 1949, the International Classification of Disease (ICD) provides common alphanumeric codes for hundreds of thousands of pathogens and health problems such as antimicrobial resistance.
Member states, including the UK, are currently using ICD-10, but this is due to be replaced by ICD-11 in January 2022.
Some independent hospitals in the UK record patient diagnoses using ICD-10, but many still use a version of its predecessor code, ICD-9.
In the independent sector, invasive procedures and surgical interventions, including biopsies, hysterectomies or hernia repairs, are recorded for billing using the Clinical Coding and Schedule Development Group (CCSD) codes. There are approximately 3,000 CCSD codes.
NHS hospitals code interventions and surgical procedures using OPCS-4 – the latest version of the Office of Population Censuses and Surveys’ Classification of Surgical Operations and Procedures.
Industry Standard Codes
Healthcode developed this coding system so independent providers could record and charge private medical insurers (PMIs) for the large numbers of services which are not covered by CCSD. There are approximately 28,000 codes covering services such as pathology, radiology and prosthetics.
Code for success
The world of clinical coding tends to be highly specialised, which is why the NHS and some larger private hospital groups employ trained and qualified clinical coding teams to code patient records for hospital episode statistics.
Few independent practitioners have the resources to employ professional clinical coders, but Healthcode’s expertise in this area can help you bridge the gap. Here are three areas where we are making clinical codes more understandable and accessible to our customers so they can operate more efficiently.
Support with billing
When billing PMIs, practitioners must use the correct procedure or service charge code and description.
Different insurers have their own schedule of procedures and fees, which means that a charge and procedure that is valid for one PMI might not be accepted by another.
Along with missing/incorrect patient information, a coding error is one of the most common reasons for an electronic bill to be rejected when Healthcode’s Clearing Service automatically checks the bill against the relevant PMI rules.
Practitioners are understandably frustrated when this happens, but it is important to stress this is not because Healthcode itself has rejected the code or code combination but because it is not accepted by that PMI.
From Healthcode’s perspective, we want to help you ensure your bills are validated first time and enter the PMI’s payment cycle without delay.
To maximise your chances of success, we recommend the following:
1. Check the PMI’s website for its schedule of procedures and fees. For example, Aviva, Axa Health, Bupa and VitalityHealth.
2. Check with the PMI at the pre-authorisation stage if you are unsure about which code applies in order to minimise the chance of rejection when you come to bill.
3. Contact Healthcode’s expert coding team if you are struggling with rejected codes, pre-authorisations and other coding queries.
We can explain what codes you can and cannot bill for and ,where necessary, we can liaise directly with PMIs to address problems and help ensure pre-authorised codes are accepted by the Clearing Service. Email us direct at firstname.lastname@example.org.
4. If you are using Healthcode’s billing software, you can simply select the correct code from the dropdown menu which learns the codes you use most frequently for that PMI.
New codes are data esperanto
Independent hospitals are required to submit information on admitted patient spells to the Private Healthcare Information Network (PHIN) which publishes performance measures about hospitals and consultants.
PHIN requires hospitals to use the same ICD-10 diagnoses and OPCS-4 procedures codes that are used in the NHS, but as noted above, independent hospitals
generally use ICD-9 and CCSD codes.
To help hospitals meet their obligations, Healthcode has developed clinical coding tools that
feature clever dual coding technology.
This enables providers to code diagnoses or procedures in the recognised format for billing and then translate, where possible, these into the equivalent ICD-10 and OPCS codes for submission to PHIN.
Simplifying procedure codes
Healthcode’s current coding project is perhaps its most ambitious and driven by the need to record practitioners’ scope of practice in a clear and accessible way on The Private Practice Register (The PPR).
Scope of practice data is needed by practitioners for appraisal and revalidation purposes, but it is also required by hospitals so they can manage consultants’ practising privileges in line with the Medical Practitioner’s Assurance Framework (MPAF).
Our Clearing Service technology enables us to capture partial scope of practice data in the form of the CCSD procedure codes used on validated hospital bills where the consultant is identified as the controlling specialist.
However, it is important that this data is presented on The PPR in an accessible format so it can be readily understood by someone with no coding training – practitioners themselves and hospital staff with governance responsibilities.
To achieve this, Healthcode is reviewing its master list of CCSD procedure codes and collating these into groups with a plain language description.
To date, we have categorised 2,000 CCSD codes into 600 unambiguous procedure groups.
For example, the procedure group ‘repair of hernia – abdominal wall’ includes 30 CCSD codes such as ‘primary repair of inguinal hernia’ (CCSD code T2000) and ‘laparoscopic repair of recurrent inguinal hernia – bilateral (CCSD code T2112). See table above for examples.
The purpose of this mammoth exercise is to make codes accessible for more people.
Users will be able to see a simple definition for the procedure group under a practitioner’s scope of practice and then expand it to see the specific CCSD codes and procedures they have performed at qualifying hospital and clinic sites over a rolling 12-month period.
We are also encouraging doctors to give us their feedback as we roll out the scope of practice capability on the PPR by specialty over the next few months to ensure the procedure groups and descriptions are clear and correct.