13^th World Pediatric Congress

Background: Clinical coding accuracy of breast surgery in the UK should be ≥90% for primary and ≥80% for secondary diagnoses as per Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures. 81% breast cancer patients in the UK undergo excisional surgery as part of their primary cancer treatment. We aimed to assess the impact of clinician’s input in achieving correct coding.

 

Methods: Clinical coding of all patients who underwent breast surgery at Blackpool Victoria Hospital, Blackpool, UK, between 01/01/2018 and 31/01/2018 were analyzed according to International Statistical Classification of Diseases and Related Health

Problems 10th Revision.

 

Results: Out of total 50 episodes, there was a significant difference in the accuracy of coding of primary (98%; n=49) and secondary diagnoses (76%; n=38) [p=0.001]. 10% of the episodes missed more than one comorbidity code. Two commonest coding errors in secondary diagnoses were obesity (10%) and heartburn (10%). Missing data (2%) and variation of interpretation of data (24%) were common causes leading to incorrect coding. With clinician’s input, a change in Healthcare Resource Group code took place in three (6%) episodes; primary diagnosis accuracy (due to missing data) remained at 98% (p=0.31), but accuracy of secondary diagnosis significantly improved to 100% (p=0.0002).

 

Conclusion: Clinical coding in breast surgery fell short of expected standard in the context of secondary diagnosis, which improved significantly following clinician’s input. Incorporation of use of coding of common co-morbidities in discharge summary and regular involvement of clinicians could improve the quality of clinical coding.