Abstract
Since the introduction of “Payment by Results”, departmental income has been linked to clinical activity, and the coding of theatre activity (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision), OPCS-4) must be accurate and timely. We assess the accuracy of OPCS-4 coding for patients having microvascular free tissue transfer for head and neck cancer, and evaluate the impact it has on departmental income. Codes for a consecutive cohort of patients were checked to identify inaccuracies and the tariffs were recalculated. Incorrect coding in 11/21 cases resulted in a financial loss of £77 449.00 because reconstruction had not been recorded as F39.1, which would automatically place it in the maximum income group, CZ04. If funding is to be optimised surgeons must be cognisant of the importance to code procedures accurately with respect to financial reimbursement. Regular monitoring of coding is suggested, including that of coexisting morbidities.
Keywords
Introduction
In July 2000 the government introduced the NHS Plan,
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which linked hospital activity to funding, and by 2008–2009 “Payment by Results”Department of Health. Payment by results 2005/6. Available from URL: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/DH_4127010.
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was being used widely. Theatre activity is quantified by the Office for Population Censuses and Surveys, version 4 (OPCS-4) coding system.5
Using Department of Health software, codes are allocated to an appropriate healthcare resource group (HRG version 4), which generates the tariff. Accuracy requires personnel to be familiar with medical terminology, surgical techniques, and the complex coding systems. 3
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A tight timetable for charging (six weeks after the end of the month of discharge) provides timely information for commissioning and payment, but errors cannot be rectified later.Clinical coding is fraught with inaccuracy.
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Previous studies have shown mistakes in coding in 7–16%Department of Health. Payment by results guidance for 2009-10 DH PbR Team; 05 February 2009. Available from URL: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_097469.pdf.
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of procedures, resulting in a considerable financial impact.In April 2009 the HRG4 tariffs for OMFS were changed from a single tariff (around £13 000) for a patient undergoing a free flap procedure, to a stepped tariff of up to £15 441 to account for coexisting morbidities.
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, Department of Health. Payment by results 2005/6. Available from URL: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/DH_4127010.
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Methods
We assessed the accuracy of OPCS-4 coding for microvascular free-tissue transfer for head and neck cancer in 21 consecutive patients for a 16-week period from April 2009, and evaluated the impact on departmental income.
Typed operating notes and OPCS-4 coding (Medway PAS, System C Healthcare plc, Maidstone, UK) were compared directly by a single clinician. Inaccuracies and changes were discussed with coding staff, and loss of income and HRG4 tariffs were recalculated after checking they met the guidelines. Ways to improve the accuracy of coding were identified and discussed.
Results
There were inaccuracies in coding for the procedures in all 21 patients (Table 1A, Table 1B), but only 11 changes were made to the HRG tariff (Table 2), which resulted in undercharging of £77 449.00. All changes were associated with the code F39.1, “Reconstruction of mouth using flap” because reconstructions of the tongue had been coded as F26.8, “Other specified operations on tongue” instead of F39.1.
Table 1AOPCS-4 (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures, 4th revision) codes entered accurately.
| OPCS-4 code | Incidence | |
|---|---|---|
| Temporary tracheostomy | E42.3 | 20/20 |
| Harvest of radial forearm free flap | Y58.9 | 13/13 |
| Block dissection of neck: | T85.1 | |
| Unilateral (15/16) | 15/16 | |
| Bilateral (3/3) | 3/3 | |
| Partial glossectomy | F22.2 | 11/12 |
Table 1BCommon missing codes.
| OPCS-4 code | Incidence | |
|---|---|---|
| Excision of submandibular gland | F44.4 | 14/17 |
| Reconstruction of mouth using flap | F39.1 | 11/21 |
| Harvest of skin for graft | S35.9 | 9/14 |
| Unspecified split autograft of skin | Y58.9 | 7/11 |
Table 2HRG (healthcare resource group) tariff by patient and change in income with new coding.
| Case no. | Tumour resected | Type of free flap | Initial HRG code | Initial HRG tariff (£) | Correct HRG code | Correct HRG tariff (£) | Difference /loss (£) |
|---|---|---|---|---|---|---|---|
| 1 | Partial glossectomy | Anterolateral thigh | CZ03Y | 2078.00 | CZ04Q | 7757.00 | 5679.00 |
| 2 | Right maxillary tuberosity | Radial forearm | CZ17Y | 2852.00 | CZ04Q | 7757.00 | 4905.00 |
| 3 | Commisure | ALT | CZ18R | 3334.00 | CZ04P | 9530.00 | 6196.00 |
| 4 | Floor of mouth/mandibulectomy | Fibula | CZ18R | 3334.00 | CZ04P | 9530.00 | 6196.00 |
| 5 | Hemiglossectomy | Radial forearm | CZ03V | 2469.00 | CZ04P | 9530.00 | 7061.00 |
| 6 | Hemiglossectomy | Radial forearm | CZ03V | 2469.00 | CZ04P | 9530.00 | 7061.00 |
| 7 | Hemiglossectomy | Radial forearm | CZ03V | 2469.00 | CZ04P | 9530.00 | 7061.00 |
| 8 | Left mandible | Fibula | CZ18R | 3334.00 | CZ04P | 9530.00 | 6196.00 |
| 9 | Partial glossectomy | Radial forearm | CZ03V | 2469.00 | CZ04P | 9530.00 | 7061.00 |
| 10 | Soft palate | Latissimus dorsi | CZ03V | 2469.00 | CZ04P | 9530.00 | 7061.00 |
| 11 | Retromolar/oropharynx | Scapula | CZ03V | 2469.00 | CZ040 | 15441.00 | 12 972.00 |
| Total | 29 746.00 | 107 195.00 | 77 449.00 |
Coexisting morbidities or complications: minor CZ04Q; intermediate CZ04P; major CZ04O. Each patient's treatment in this group lost income. All had been coded as tongue or palate resection rather than mouth or buccal.
Discussion
The current system for the coding of major head and neck operations results in a loss of income. Accurate coding requires understanding of the current OPCS-4 system,
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and operative procedure. Staff who record the codes are not familiar with surgical technicalities and clinical staff are not familiar with coding protocols. We did not compare these two groups but aimed to establish where the inaccuracies occurred and to put forward strategies to avoid them.The failure to use F39.1, “Reconstruction of mouth using flap” has serious financial implications as its use places the episode into the HRG category “Complex major mouth procedure”, which generates the maximum tariff (£7757.00 with no complications and no coexisting morbidities [HRGCZ04Q]; £9530.00 [HRGCZ04P] for intermediate; or £15 441.00 [HRGCZ04O] for major complications).
In 2008–2009 we received an income of £13 000/patient. HRG4 tariffs are now considerably lower and only two patients’ operations were placed in the HRG CZ04O category. Such loss of income will be made worse if procedures are coded incorrectly and miss being placed in the HRG CZ04 (maximum tariff) group. Table 3 shows the 20 procedures that are automatically placed in this group.
Table 3Procedures and codes in the CZ04 (maximum tariff) group.
| Procedures in the CZ04 (maximum tariff) group | |
|---|---|
| E191 | Total pharyngectomy |
| E192 | Partial pharyngectomy |
| E291 | Total laryngectomy |
| E292 | Partial horizontal laryngectomy |
| E293 | Partial vertical laryngectomy |
| E294 | Partial laryngectomy NEC |
| E295 | Laryngofissure and chordectomy of vocal chord |
| E296 | Laryngectomy NEC |
| E298 | Other specified excision of larynx |
| E299 | Unspecified excision of larynx |
| E311 | Laryngotracheal reconstruction using cartilage graft |
| E312 | Laryngotracheoplasty NEC |
| E313 | Division of stenosis of larynx and insertion of prosthesis into larynx |
| E356 | Endoscopic partial laryngectomy |
| F221 | Total glossectomy |
| F243 | Glossotomy |
| F391 | Reconstruction of mouth using flap NEC |
| T961 | Excision of cystic hygroma |
| V074 | Excision of lesion of infratemporal fossa |
| V141 | Hemimandibulectomy |
NEC: not elsewhere classified.
Clinicians are no better at providing accurate codes than administrative staff,
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but operating notes that use a proforma allow the most appropriate codes for maximum income to be selected, with F39.1 as the default code. Coding should be checked in a timely fashion to allow changes to be made, and at the end of the financial year alterations to the HRG tariff system should be identified.Clear documentation of coexisting morbidities and complications is essential to obtain the high level tariff. They must be recorded using medical terminology—for example, pneumonia, not chest infection. Coding could be linked to existing oncology databases to enable easier data capture and retrospective audit.
References
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Article info
Publication history
Published online: March 08, 2011
Accepted:
January 10,
2011
Identification
Copyright
© 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
