I read with interest the paper by Moar and Rogers.
1
Accuracy of coding is important not only for financial reasons but also for indicators
of quality.
2
The two main elements that can affect it are the quality of the source of the documentation
(the operation note) and the coding of comorbidities. I have developed SurgiNote™,
which is an operation note database (Appendix 1). Using a series of drop-down boxes and a filtration system, the surgeon is able
to select the surgical specialty, individual surgical procedures, and the OPCS code.
The American Society of Anesthesiologists’ (ASA) grade along with relevant comorbidities
can also be entered. The indication, findings, operation, and postoperative and discharge
instructions are entered as free text.To read this article in full you will need to make a payment
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References
- Impact of coding errors on departmental income: an audit of coding of microvascular free transfer cases using OPCS-4 in UK.Br J Oral Maxillofac Surg. 2012; 50: 85-87
- Performance and quality indicators: the importance of accurate coding.Ann R Coll Surg Engl (Suppl). 2012; 94: 46-50
- The surgical operation note database: improving the accuracy and quality of operation note keeping.Ann R Coll Surg Engl (Suppl). 2011; 93: 1-6
Article info
Publication history
Published online: April 09, 2012
Identification
Copyright
© 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.