First seen in Independent Practitioner Today
In the first of a new series, Peter Connor provides an introduction to coding – something independent practitioners need to be increasingly savvy about.
Codes seem alien to the way that most of us communicate. If we think of them at all, it’s probably in the context of wartime and the efforts of the mathematical geniuses at Bletchley Park to decipher the Germans’ encrypted messages into plaintext with the help of the first computing machines.
But in a clinical context, it’s not so easy to pigeonhole codes as the exclusive province of boffins and computers. Some of the major health challenges we face, such as halting the spread of disease, measuring the effectiveness of treatment and allocating sufficient resources to healthcare, can only be addressed properly with the help of statistical information.
However, it would be impossible to collect, store and share the quantity of information required without the use of codes. Clinical codes translate unwieldy lines of text in different languages into a common currency which is conducive to computer analysis. Coding has become an essential tool for standardising the classification of disease and its treatment and as I will show, something which is set to play an increasing role in independent practice.
A brief history of classification and coding
Perhaps the earliest example of how information has proved invaluable in the fight against disease is the weekly publication of London Bills of Mortality in the seventeenth century which were seized on by city-dwellers to identify and avoid bubonic plague black spots. One London merchant called John Graunt spotted that this information could be used to analyse the long-term incidence deaths from diseases such as tympany (tumours) and the King’s Evil (scrofula) and in 1662 he published a pioneering statistical analysis of population and causes of death over a 70-year period: Natural and Political Observations made upon the Bills of Mortality.
Two centuries later, during a cholera epidemic of 1854, the famous epidemiologist, Dr John Snow, was able to draw on the more detailed statistical data published by Dr William Farr at the General Register Office to trace a cluster of deaths close to a public water pump in Soho. Dr Snow’s work helped conclusively prove that cholera was water-borne and disproved the widespread belief that a poisonous miasma was to blame for the disease.
Growing recognition of the value of cause of death statistics led in 1893 to the first International List of Causes of Death being adopted by the International Statistical Institute. But epidemiologists and statisticians were already beginning to understand that the classification of deaths would only take them so far – the ability to classify and analyse disease was equally important. This was only achieved after the foundation of the World Health Organisation (WHO) in the aftermath of the Second World War.
Adopted by the WHO in 1949, the International Classification of Disease (ICD) provides common alphanumeric codes for thousands of diseases and health problems so that data can be stored and shared between healthcare providers using an easily referenced common language. The latest version - ICD-10 - was endorsed in May 1990 and came into use in 1994 with the next revision expected in 2015.
Today, ICD has become the international standard for defining and reporting diseases and health conditions. It is used to study patterns of diseases such as malaria, AIDS and SARS and is widely used to manage healthcare, monitor outcomes and allocate resources. In fact, the WHO currently estimates that about 70% of the world’s health expenditures are allocated using ICD for reimbursement and resource allocation.
Coding and classification systems
Diagnostic coding is one area of health activity that needs to be classified and analysed. Different systems are employed to record episodes of treatment, including surgical interventions. In the next two articles I will look in more detail at the way coding is used in independent practice but for now, it may help to briefly explain what systems are used and how they differ from the way information is recorded in the NHS.
Diagnostic coding: While the WHO’s ICD-10 of over 14,000 codes is used by the NHS hospitals to record morbidity (READ coding is the standard system used in general practice), the independent healthcare sector is using a version of its predecessor, ICD-9, which was first introduced in 1975 and contains around 7,000 codes.
Treatment coding: In the NHS, the alphanumeric coding system used was first developed by the Office of Population Censuses and Surveys and is therefore known as OPCS classification of interventions and procedures (currently OPCS-4). It is now overseen by the NHS Classifications Service and updates are published around every two years. The most recent edition - OPCS-4.6 consists of more than 6,000 codes which are arranged anatomically.
Within the independent sector, the system of alphanumeric procedure codes to represent procedures was developed by the Clinical Coding & Schedule Development (CCSD) Group and introduced in January 2006. The CCSD Group consists of representatives from five major private insurers and its work is coordinated by Capita Health which also liaises with the main private hospital groups to ensure codes have equivalent hospital classifications. CCSD codes and narratives currently reflect over 2,000 procedures carried out privately.
Non-procedural services: However, the majority of independent practice is not covered by the CCSD codes. Non-procedural activities such as outpatients’ appointments, pathology, pharmacology and radiology. Here Healthcode has stepped in to develop a proprietary system of Industry Standard Charge Codes so that independent practitioners can record and charge insurers for this work. Industry Standard Charge Codes has been going for 15 years and more recently standard codes for pathology services and charges have been introduced, similar projects are underway for radiology, drug and prosthetic services.
Coding on the agenda in independent practice
The importance of coding has long been recognised in the NHS (for example, codes are used to produce Hospital Episode Statistics and used for Payment By Results) but this work is carried out by teams of clinical coders, trained by the NHS Classifications Service. Few clinicians will have had much to do with the process beyond attending a presentation about coding during their hospital induction or being asked to provide additional information about their diagnoses or treatment to assist the coding process.
By contrast, independent practitioners cannot afford to remain detached from coding. For a start, Private Medical Insurers (PMIs) generally expect providers to include descriptions and appropriate CCSD codes on their invoices which means that independent practitioners or their PAs need to have some familiarity with assigning procedure codes.
There is also increasing pressure from outside and within the private healthcare sector to measure Quality and Outcomes so that services can be benchmarked (against each other and the NHS) and this depends on the consistent and accurate use of codes. Private hospital groups are already taking part in a project to measure private hospital episodes through a new body called the Private Healthcare Information Network (PHIN) but the focus will inevitably shift to individual consultants in due course.
In addition, the GMC now expects doctors to provide audits as supporting evidence during their annual appraisals (which in turn are essential for revalidation) but few independent practitioners will have the time and resources to do this manually. By contrast, the use of coding will give doctors a head start when it comes to producing anonymised practice audits because it allows information to be easily stored, retrieved and analysed.
To sum up, coding may initially seem like an unwelcome distraction from treating patients but I hope I’ve convinced you of its value and its growing potential. Over the next two articles I will explore in more detail how practitioners can approach diagnosis and treatment coding in the context of the challenges facing the independent health sector.