643 Audit of Accuracy of Clinical Coding for Complex Abdominal Wall Surgeries
K Gargan, L Awad, M Curtis, A Naveen, Y Al-AjamAbstract
Aim
Accurate coding is crucial to ensure appropriate remuneration for clinical procedures. The coding process is prone to error as coders, who are non-clinical, rely on clinical documentation to determine what they believe are the appropriate ICD and OPCS-4 codes. This is particularly complex in plastic surgery where operations often have subtle differences. This study audited the accuracy of coding of complex abdominal wall reconstructive operations in the Royal Free Hospital and reviewed its financial implications.
Method
Patients were included who underwent complex abdominal wall reconstructive surgeries, which we defined as requiring both general surgery and plastic surgery input, between August and November 2024. Their overall HRG codes, and corresponding ICD and OPCS-4 codes, were reviewed for accuracy based on documentation available for each patient. Results were discussed with senior clinicians and the clinical coding team and HRG codes were amended as appropriate.
Results
Overall, four cases were included. Changes were made to ICD and OPCS-4 codes in all 4 cases. The addition of the clinician-validation process led to more accurate coding for these cases, resulting in significant financial savings of, on average, £6,000 per case.
Conclusion
This audit emphasised the importance of collaboration between clinicians and coders to ensure accurate clinical coding and minimise potential financial loses for NHS trusts. Increased awareness of clinical coding by the clinical team and clear documentation are essential.