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Re: Impact of coding errors on departmental income: an audit of coding of microvascular free transfer cases using OPCS-4 in UK

      I read with interest the paper by Moar and Rogers.
      • Moar K.K.
      • Rogers S.N.
      Impact of coding errors on departmental income: an audit of coding of microvascular free transfer cases using OPCS-4 in UK.
      Accuracy of coding is important not only for financial reasons but also for indicators of quality.
      • Cockbain A.J.
      • Carolan M.
      • Berridge D.
      • Toogood G.J.
      Performance and quality indicators: the importance of accurate coding.
      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.
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      References

        • Moar K.K.
        • Rogers S.N.
        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
        • Cockbain A.J.
        • Carolan M.
        • Berridge D.
        • Toogood G.J.
        Performance and quality indicators: the importance of accurate coding.
        Ann R Coll Surg Engl (Suppl). 2012; 94: 46-50
        • Chiu G.A.
        • Woodwards R.T.
        The surgical operation note database: improving the accuracy and quality of operation note keeping.
        Ann R Coll Surg Engl (Suppl). 2011; 93: 1-6