For decades now, coded data has been used to ensure hospitals can be reimbursed for their activity and better plan for services in the future.

Clinical coding usually occurs after the patient has been discharged from hospital, where information written in patient notes is translated into coded data and entered into hospital information systems.

It is important that hospitals code episodes of care accurately to ensure the right resources to provide care for patients is received. For Northern Health, coding helps to fund our clinical services and equipment needs.

Medical Unit 4 at Northern Hospital Epping has been involved in a coding audit review process for over four years.

The process involves the whole team meeting with Patricia Savino, Health Information Manager (HIM), on a monthly basis and answering any clinician questions about documentation.

Northern Health’s regular audit is a great example of ensuring data is accurately reflecting the patient’s episode of care, and we are optimising our eligible Weighted Inlier Equivalent Separation (WIES) income. Medical Unit 4 has achieved 77.10 WIES YTD – that’s $372,624! This figure is expected to double for the remainder of the year.

Medical Unit 4 Consultant, Sandeep Sharma, says “our monthly meetings are a great opportunity for our Unit Clinicians to come together and discuss complex patients, and for our junior staff to see how clarification in documentation can lead to significant changes in funding.”

“We know it’s imperative for our junior medical staff to learn financial aspects of medicine, as we do not live in the world with unlimited resources,” Sandeep says.

Frances Barnett, Medical Director Oncology, has been interested to learn more about WIES optimisation and data quality improvements after Mary Kouvas (pictured above), Clinical Documentation Specialist (CDS), spoke at a Heads of Unit meeting.

Frances believes there is an opportunity for doctors to have a better understanding that documentation has both a clinical and revenue purpose. An example of this is the diagnosis of pneumonia treated with antibiotics.

“To me, this means a bacterial pneumonia, but a coder requires bacterial pneumonia to be specified rather than implied. If the documentation is done for both purposes the first time, it is more efficient for everyone,” Frances says.

“I have set up regular meetings for 2019 so that my junior medical staff can learn how the process works, thereby reducing the need for queries to be generated and answered.”

Another way of improving data is by being involved in the documentation improvement process on the ward. Mary Kouvas reviews concurrent medical records to ensure the documentation is written in a specific way the coders can translate into codes. This Clinical Documentation Improvement (CDI) program looks at improving documentation in real-time, to reduce re-work at a later date.

If you wish to get involved and reap the benefits, please email mary.kouvas@nh.org.au or call CDS on 8405 2038.

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