The accuracy of clinical coding in the NHS in England is improving, says the Audit Commission in its latest annual report on its audits of data that underpin payment by results, the tariff payment system for acute hospitals. But there is room for improvement, including in medical record-keeping.
Coding errors are fewer than in 2007, when the Audit Commission began checking the Payment by Results (PbR) system. The new report, Improving data quality in the NHS, shows that the average clinical coding error rate has dropped from 16 per cent to 11 per cent in three years.
Over the last three years, the Audit Commission has looked at over £200 million worth of payments for in-patient treatments and found that some trusts are significantly better than others at clinical coding. From this sample, some £9 million (about 5 per cent) worth of financial errors have been spotted. (See full report, Improving data quality in the NHS.)
Since 2007 the Commission has carried out random sample audits on four specific specialties at all trusts that deliver them, to give a national picture across the NHS in England. The four specialties are: general medicine, trauma and orthopaedics, cardiology, and paediatrics. The Commission estimates that out of the £21 billion paid over the last three years for treatments in these specialties, £1 billion (about 5 per cent) was incorrectly paid because of wrong data.
Andy McKeon, the Audit Commission's Managing Director, Health, said:
'It's reassuring that the NHS is getting better at clinical coding. Efficiency is more important than ever and accurate clinical coding under payment by results will contribute to better data, better decisions and better outcomes for patients.
'But the variation in error rates from trust to trust is a concern. There are clear ways in which trusts can improve and we'll be focusing our 2010/11 clinical coding audits on the trusts that most need help. We will also be auditing the costing submissions of acute trusts that underpin the tariff and which are also used in local price negotiations.'
A key finding is that there remains no evidence of systematic 'gaming' in the system, in other words, NHS trusts purposely using wrong codes to get extra money for treatments that were not provided, or charging for a more expensive treatment than was provided. On the sample audited, NHS trusts have slightly undercharged primary care trusts (PCTs) for their work in 2009/10.
But there is significant variation locally. In more than a quarter of trusts audited by the Commission, PCTs would pay 2 to 8 per cent more for some treatments if the NHS trust had coded them accurately.
The gap between the best and worst trusts at clinical coding has narrowed. But the range from 0 to 28 per cent is still high. The Commission audited outpatient payment data for the first time in 2009/10. The average error rate was 5.2 per cent, with a range of between 0 and 45 per cent.
Trusts have improved their coding and clinical coding staff are now better trained. Greater clinical engagement would further improve the accuracy of the data. Additional improvements would result from trusts carrying out regular internal audits on clinical coding and ensuring that policies and procedures are up to date. Poor medical records continue to be a source of error. These represent a clinical as well as financial risk.
Notes for editors
- Under Payment by Results (PbR) NHS trusts claim payments for each treatment they provide and there is a different code for individual operations (e.g. a hip replacement or a cataract removal).
- The PbR Data Assurance Framework is designed to support data quality improvement in the NHS. It reviews the quality of key data that underpin payment under PbR and provides assurance that data is of sufficient quality for the system to function robustly. The framework was developed by and is managed by the Audit Commission.
- The new report presents key findings and a summary analysis of a sample of clinical coding audits of admitted patient care data carried out all acute trusts in England during 2009/10. This is the third year of the programme. It also reports on audits of outpatient data.
- The Commission won a national award for its PbR National Benchmarker in 2009. The Commission's health sector initiative was joint overall winner in the Excellence in Healthcare Information Management category at the BT-sponsored e-Health Insider Awards. It is used by over 3,000 people at NHS trusts, foundation trusts, primary care trusts and strategic health authorities.
- The PbR data assurance framework programme for 2010/11 will continue. The Commission will discuss the 2011/12 programme with the Department of Health later this year. The Commission will also make its experience and knowledge in providing assurance on PbR data available to the Department of Health, the NHS Commissioning Board, Monitor and the NHS Information Centre to inform their consideration of what, if any, arrangements should be in place following the abolition of the Commission and PCTs.
- The Audit Commission is an independent watchdog, driving economy, efficiency and effectiveness in local public services to deliver better outcomes for everyone. More details: audit-commission.gov.uk
- The Commission's work across local government, health, housing, community safety and fire and rescue services means that we have a unique perspective. We promote value for money for taxpayers, auditing the £200 billion spent by 11,000 local public bodies. As a force for improvement, we work in partnership to assess local public services and make practical recommendations for promoting a better quality of life for local people.
Nigel Watts
Media Relations Manager
Audit Commission
020 7166 2129 | 07813 315538 | nigel-watts@audit-commission.gov.uk