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PubMed2000

Case study: clinical documentation improvement program supports coding accuracy.

Developing a comprehensive inpatient clinical documentation and coding improvement program that demonstrates successful outcomes and proves to be sustainable by the health care organization is a difficult process but significant in maintaining accurate coding and reimbursement under the Medicare system. This case study of one health care organization that undertook just such a comprehensive program, chronicles the steps involved, the categories of health care professionals necessary to support ongoing communication and education, and the need for physician partnerships to sustain the program and achieve results. The program had a positive impact with a net increase in reimbursement attributed directly to the case reviews and point of service clinical education. Creating a new position of Coding/Documentation Specialist, working at the point of care as a regulatory interpreter and coding expert, was found to be key to cementing the successful team approach to documentation quality.

Abstracting and Indexing↗
PubMed2003

Development of a quality use of medicines coding system to rate clinical pharmacists' medication review recommendations.

OBJECTIVE: To develop a 'quality use of medicines' coding system for the assessment of pharmacists' medication reviews and to apply it to an appropriate cohort. METHOD: A 'quality use of medicines' coding system was developed based on findings in the literature. These codes were then applied to 216 (111 intervention, 105 control) veterans' medication profiles by an independent clinical pharmacist who was supported by a clinical pharmacologist with the aim to assess the appropriateness of pharmacy interventions. The profiles were provided for veterans participating in a randomised, controlled trial in private hospitals evaluating the effect of medication review and discharge counselling. The reliability of the coding was tested by two independent clinical pharmacists in a random sample of 23 veterans from the study population. MAIN OUTCOME MEASURE: Interrater reliability was assessed by applying Cohen's kappa score on aggregated codes. RESULTS: The coding system based on the literature consisted of 19 codes. The results from the three clinical pharmacists suggested that the original coding system had two major problems: (a) a lack of discrimination for certain recommendations e.g. adverse drug reactions, toxicity and mortality may be seen as variations in degree of a single effect and (b) certain codes e.g. essential therapy were in low prevalence. The interrater reliability for an aggregation of all codes into positive, negative and clinically non-significant codes ranged from 0.49-0.58 (good to fair). The interrater reliability increased to 0.72-0.79 (excellent) when all negative codes were excluded. Analysis of the sample of 216 profiles showed that the most prevalent recommendations from the clinical pharmacists were a positive impact in reducing adverse responses (31.9%), an improvement in good clinical pharmacy practice (25.5%) and a positive impact in reducing drug toxicity (11.1%). Most medications were assigned the clinically non-significant code (96.6%). In fact, the interventions led to a statistically significant difference in pharmacist recommendations in the categories; adverse response, toxicity and good clinical pharmacy practice measured by the quality use of medicine coding system. CONCLUSION: It was possible to use the quality use of medicine coding system to rate the quality and potential health impact of pharmacists' medication reviews, and the system did pick up differences between intervention and control patients. The interrater reliability for the summarised coding system was fair, but a larger sample of medication regimens is needed to assess the non-summarised quality use of medicines coding system.

Aged↗
PubMed1989

Development of a coding system for recording clinical findings in farm animal practice.

A coding system was developed for recording veterinary information in the University of Liverpool farm animal practice. Existing coding systems were found to be unsuitable for use on a microcomputer in a veterinary practice. A number of new coding formats were developed and tried. The need to record varying detail, to analyse data and to enter data quickly resulted in biaxial hierarchical codes. These are used in an automated coding system to record all veterinary and reproduction information in the practice.

Animals↗
PubMed1999

An audit of diagnostic coding in genitourinary medicine clinics. Trent Region Genitourinary Medicine Audit Group.

The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments. We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations. The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course. Coding practice also varied within individual sites with a 21-100% discordance. In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.

Female Urogenital Diseases↗
PubMed1993

Assessment of global and regional myocardial function using the Minnesota Q/QS codes. A comparison with clinical ECG interpretation.

The authors investigated 244 consecutive patients with suspected coronary artery disease by coronary angiography and quantitative left ventriculography to compare the Minnesota Q/QS code (MC) with clinical electrocardiographic (ECG) interpretation. Patients who were suspected to have wall motion abnormalities for reasons other than coronary artery disease for possible regional wall motion abnormalities were excluded. Out of 244 patients, 159 (65%) had wall motion abnormalities. The sensitivity for detecting wall motion abnormalities was 21% for MC 1.1 and 51% for MC 1.1-3, whereas clinical ECG interpretation showed a sensitivity of 73%. Specificity for MC 1.1 was 93% and for MC 1.1-3 it was 84%. Specificity of clinical ECG interpretation (84%) was comparable. Compared to the MC, clinical ECG interpretation showed a stronger association with left ventricular ejection fraction, number of segments with abnormal wall motion, and severity of wall motion abnormality. Anterior myocardial infarction presented more often with clinical ECG changes (71%) and with a Q/QS code (50%) than inferior myocardial infarction (61% and 41%, respectively). In summary, in contrast to clinical ECG criteria, the MC has high specificity at the expense of a low sensitivity.

Cineradiography↗
PubMed2006

[Use and evaluation of the Belgian 3BT thesaurus adapted for Rwanda].

The Kigali university medical centre (CHUK) lacks visibility on its activities for many years. Institution management as well understanding the institution as the corner stone of the Rwandese health system and reinforcement of its visibility are all health policy major issues. Nevertheless, to this point no such tool has been developed nor implemented. The objective is to assess the feasibility of the use of the thesaurus 3BT as data collection tool in a Rwandese health institution. In august 2005, the thesaurus 3BT (Belgian, bilingual, biclassified ICD-10/ICPC-2) adapted to the CHUK has been implemented. Main issues: encoding quality and thesaurus operationality. Qualitative analysis has been performed on 899 coding of which 16 empty. Low occurrences (< or = 0.2%) of about 25% of codings of clinical diagnosis show the need for using a thesaurus but also to upgrade it. Near 45% of the empty codings could be fulfilled with a quick look to the original medical record. Some diagnoses are missing in the thesaurus 3BT. 66% of which have similar concepts in the thesaurus although not identifiable by a lay person. Finally, a clinical data blind coding test by a doctor used to classifications and by a lay person used to code clinical diagnosis from medical records of the hospitalised patients shows an exact similarity in 70% of the coding and a loss of coding precision in 20%. No coding error has been identified at this time. In conclusion, operationality of the thesaurus is quite acceptable in this study. The thesaurus makes easy the coding of clinical diagnosis even by lay people. Quality of data is enough to be able to interpret the quantitative results of the coding process. This study has to be repeated on a wider basis.

Belgium↗
PubMed2000

Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life.

OBJECTIVE: To assess the effect of newborn circumcision on the incidence and medical costs of urinary tract infection (UTI) during the first year of life for patients in a large health maintenance organization. SETTING: Kaiser Permanente Medical Care Program of Northern California (KPNC). PATIENTS: The population consisted of members of KPNC. The study group consisted of a cohort of 28 812 infants delivered during 1996 at KPNC hospitals; of the 14 893 male infants in the group, 9668 (64.9%) were circumcised. A second cohort of 20 587 infants born in 1997 and monitored for 12 months was analyzed to determine incidence rates. DESIGN: Retrospective study of all infants consecutively delivered at 12 facilities. OUTCOME MEASURES: Diagnosis of UTI was determined from the KPNC computerized database using the International Classification of Diseases, Ninth Revision code for inpatients and KPNC Outpatient Summary Clinical Record codes for outpatients. A sample of 52 patient charts was reviewed to confirm the International Classification of Diseases, Ninth Revision and KPNC Outpatient Summary Clinical Record codes and provide additional data. RESULTS: Infants <1 year old who were born in 1996 had 446 UTIs (292 in females; 154 in males); 132 (86%) of the UTIs in males occurred in uncircumcised boys. The mean total cost of managing UTI was 2 times as high in males ($1111) as in females ($542). This higher total cost reflected the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared with females (7.5%); mean age at hospitalization for UTI was 2.5 months old for uncircumcised boys and 6.5 months old for girls. In 1996, total cost of managing UTI in uncircumcised males ($155 628) was 10 times higher than for circumcised males ($15 466) despite the fact that uncircumcised males made up only 35.1% of the male patient base in 1996, reflecting the more frequent occurrence of UTI in uncircumcised males (132 episodes) than in circumcised males (22 episodes), and the larger number of hospital admissions in uncircumcised males (38) than in circumcised males (4). The incidence of UTI in the first year of life was 1:47 (2.15%) in uncircumcised males, 1:455 (.22%) in circumcised males, and 1:49 (2. 05%) in females. The odds ratio of UTI in uncircumcised:circumcised males was 9.1:1. CONCLUSIONS: Newborn circumcision results in a 9. 1-fold decrease in incidence of UTI during the first year of life as well as markedly lower UTI-related medical costs and rate of hospital admissions. Newborn circumcision during the first year of life is, thus, a valuable preventive health measure, particularly in the first 3 months of life, when uncircumcised males are most likely to be hospitalized with severe UTI.

California↗
PubMed1996

The efficacy of SNOMED, Read Codes, and UMLS in coding ambulatory family practice clinical records.

This study was initially developed as a traditional quantitative study to determine the level of match of identified clinical terms in three (3) clinical vocabularies. To address concerns raised by a review of the literature and our own experience, a supplemental study to collect qualitative data was added. Dictated progress notes from a stratified sample of patient visits over a period of four (4) years were used to obtain a representative sample of terms. A total of 144 progress notes were selected taking into consideration the usual demographics plus additional variables. From the 144 clinical notes, 864 terms were extracted and evaluated by level of match. The within-term effect was highly significant (F = 58.69, p < or = .001), indicating significant differences in the mean level of match for the three coding systems. Qualitative findings suggest that this and other published studies may not answer questions about the "efficacy of available clinical vocabularies in coding ambulatory family practice clinical records", and additional studies are needed which must be carefully structured and utilize a standardized procedure.

Family Practice↗
PubMed1996

Using bar-code technology to capture clinical intervention data in a hospital with a stand-alone pharmacy computer system.

The use of bar-code technology to capture data on pharmacists' clinical interventions is described. At a hospital in Northern Ireland, patient-specific information could not be accessed through the pharmacy computer system. A system comprising six hand-held bar-code readers and software for downloading data was purchased. The pharmacy staff selected a range of fields for recording a wide array of data on clinical interventions, including the outcomes. Patient details that could not easily be bar-coded had to be recorded manually. The process was evaluated over three four-week cycles, with the data fields being revised after each cycle and the interventions being judged for their clinical appropriateness and their conformance to inhouse standards. After the third cycle, the need for manual recording of information was eliminated. A total of 857 interventions were made during the three cycles. Performance met or exceeded the standard for 7 (50%) of 14 indicators for the first cycle, 8 (53%) of 15 for the second cycle, and 13 (81%) of 16 for the final cycle. For all three cycles, the majority of the interventions were important and resulted in an improvement in the standard of care. A bar-code-driven data collection system successfully replaced a manual system for documenting pharmacists' clinical interventions.

Clinical Pharmacy Information Systems↗
PubMed2004

The European Register for Specialists in Clinical Chemistry and Laboratory Medicine: Code of Conduct.

The European Communities Confederation of Clinical Chemistry and Laboratory Medicine (EC4) opened a Register for European Specialists in Clinical Chemistry and Laboratory Medicine in 1997. The operation of the Register is undertaken by a Register Committee (EC4RC). During the last 6 years more than 1500 specialists in clinical chemistry and laboratory medicine have joined the Register. In this article a Code of Conduct for Registrants which was approved at the EC4 Register Committee meeting in Amsterdam, 8 November 2003 is presented.

Chemistry, Clinical↗
PubMed2003

Cancer associated with obstetric delivery: results of linkage with the California cancer registry.

OBJECTIVE: This study provides revised population-based measurements for the occurrence rates of cancer associated with obstetric delivery and examines perinatal and cancer-related outcomes within the group of women with 4,846,505 obstetric deliveries in California, inclusive of the years 1991 through 1999. STUDY DESIGN: This observational study used a population-based retrospective review of cases identified as a result of computer linkage of maternal/neonatal hospital discharge and birth/death records with case files in the California Cancer Registry (CCR). The effect of timing of cancer diagnosis on clinical outcomes was studied by dividing the cases into three groups as follows: "prenatal" for cancer diagnosis within 9 months before delivery, "at delivery" for cancer diagnosis during delivery hospitalization, and "post partum" for cancer diagnosis within 12 months after delivery. Computerized records for 4,846,505 obstetric patients and 4,906,920 newborn infants comprising the linked vital statistics birth/patient discharge database (VS/PDD) were used to identity-match cases within the CCR case files. Cases of malignant disease were categorized into 22 anatomic or histologic subgroups. Perinatal clinical outcomes including preterm delivery, prolonged neonatal hospital stay, stillbirth, neonatal death, frequency of first trimester prenatal care, and cesarean delivery were analyzed by use of International Classification of Diseases, 9th Revision, Clinical Modification codes from the VS/PDD. Clinical cancer outcomes including cancer stage and vital status on follow-up were drawn from CCR records. Statistical comparisons for trends were performed with the Cochran-Armitage test, outcomes comparisons with the Fisher exact test, and survival comparisons were performed with the Cox proportional hazard model. RESULTS: Among 4,846,505 obstetric deliveries, 4,539 cases of invasive malignancy were identified for an observed occurrence rate of 0.94 per 1000 births. Sixty-four percent of the cases occurred post partum; cancers of the breast, thyroid, cervix, along with malignant melanoma, and Hodgkin's disease accounted for 64% of the cases. The timing of cancer diagnosis affected clinical outcomes: for all cancer cases as a group, the most favorable perinatal and cancer outcomes occurred in women whose cancer diagnosis was made 6 to 9 months before delivery (6% of cases). The most unfavorable perinatal and cancer outcomes were associated with cancer diagnosis made 0 to 3 months before delivery (14% of cases). For women whose cancer was diagnosed post partum, perinatal outcomes were minimally affected by the presumed existence of occult cancer at the time of obstetric delivery. CONCLUSION: The use of computer-linkage to the CCR files enhanced identification of cases of maternal malignancy associated with obstetric delivery. Cancer diagnosis was associated with approximately 1 in 1000 deliveries. Most cases were diagnosed after delivery and were comprised predominantly of cancers of the breast, thyroid, cervix, malignant melanoma, and Hodgkin's disease. A small group of women (approximately 1 per 5000 deliveries) are seen within a few months before delivery or at delivery with malignant disease, many of whom have rapidly progressing disease and may require high-risk perinatal and oncology services.

Breast Neoplasms↗
PubMed2004

Code of Professional Conduct for Clinical Embryologists.

The Association of Clinical Embryologists (ACE) is the professional body of and for clinical embryologists practising in the UK. ACE was founded in 1993 to promote high standards of practice in clinical embryology and to support the professional interests of embryologists. ACE presently has in excess of 400 members.

Codes of Ethics↗
PubMed2005

Understand the "fine print" when selecting the correct codes for patient admissions from clinic to hospital.

How should a physician code and bill for services when a patient is seen in the clinic and then is directly admitted to the hospital? The correct answer is not as straightforward as it might at first seem because of needing to understand what amounts to the "fine print" in the Current Procedural Terminology (CPT) book code description. It also depends on whether or not the physician subsequently had face-to-face contact with the patient in the hospital. According to the CPT book, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. physician's office) all evaluation and management services (E/M) provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission s/he provided in the other sites of service as well as in the inpatient setting." At first, this wording could lead physicians and coders to conclude that their only recourse is to "roll up" the level of service provided in the clinic with the additional documentation necessary to admit a patient to the hospital to determine the code for "Initial Hospital Care", CPT 99221-99223. However, it has been noted that the description in the CPT book under initial hospital care has "fine print" in the statement the "codes are used to report the first hospital inpatient encounter with the patient by the admitting physician." "Encounter" is commonly understood to mean a "face to face" encounter between the physician and patient in the hospital setting. But, what if the physician does not go to the hospital to see the patient on the same date that s/he saw the patient in the clinic? Because a face to face encounter in the hospital did not occur, it would be inappropriate to use any of the "Initial Hospital Care" CPT 99221-99223 codes. Rather, the services of the clinic visit should be billed as "new" or "established" patient office visit on the date seen and the initial hospital service would be billed on a following date when the physician actually sees the patient in the hospital setting.

Ambulatory Care Facilities↗
PubMed1991

Code of practice for clinical proton dosimetry.

The objective of this document is to make recommendations for the determination of absorbed dose to tissue for clinical proton beams and to achieve uniformity in proton dosimetry. A Code of Practice has been chosen, providing specific guidelines for the choice of the detector and the method of determination of absorbed dose for proton beams only. This Code of Practice is confined specifically to the determination of absorbed dose and is not concerned with the biological effects of proton beams. It is recommended that dosimeters be calibrated by comparison with a calorimeter. If this is not available, a Faraday cup, or alternatively, an ionization chamber, with a 60Co calibration factor should be used. Physical parameters for determining the dose from tissue-equivalent ionization chamber measurements are given together with a worksheet. It is recommended that calibrations be carried out in water at the centre of the spread-out-Bragg-peak and that dose distributions be measured in a water phantom. It is estimated that the error in the calibrations will be less than +/- 5% (1 S.D.) in all cases. Adoption and implementation of this Code of Practice will facilitate the exchange of clinical information.

Cobalt Radioisotopes↗
PubMed2005

The multi-institutional validation of the new screening index for physical child abuse.

BACKGROUND/PURPOSE: There is currently no evidence-based screening instrument to assist in the detection of physical child abuse patients. The screening index for physical child abuse (SIPCA) was previously developed as a potentially new tool for this need. It is a scale that assigns point values, on the basis of variable weights from logistic regression models, to age and patterns of injuries (including fracture of base or vault of skull, contusion of eye, rib fracture, intracranial bleeding, multiple burns), with higher scores indicating greater suspicion for abuse. The purpose of this study is to validate this new tool in another independent data set. METHODS: A cross-sectional hospital discharge database from 1961 hospitals in 17 states is used (n = 58558). Children aged 14 years or younger with International Classification of Diseases, Ninth Revision, Clinical Modification codes 800 to 959 are included for analysis. Child abuse cases are identified by E codes and certain International Classification of Diseases, Ninth Revision, Clinical Modification codes in the 995.5x range. Screening index for physical child abuse performance is evaluated by discrimination (receiver operating characteristic) and goodness of fit (pseudo r2). RESULTS: A total of 447 abused patients (0.76%) was identified. The receiver operating characteristic of SIPCA in this data set is 0.89 as compared with 0.86 in the development data set. The pseudo r 2 of SIPCA in this data set is 0.26 as compared with 0.28 in the development data set. A SIPCA score of 3 has a sensitivity of 86.6% and a specificity of 80.5% for detecting physical abuse; raising the threshold to a score of 4 improves the specificity to 93.1% but at a loss of sensitivity to 71.8%. CONCLUSIONS: The validity of the new SIPCA instrument is supported by its performance in an independently derived data set. A score of 3 on SIPCA represents a balanced trade off in the sensitivity and specificity of the instrument in detecting physical abuse and is an optimal threshold above which to begin considering abuse in differential diagnosis. Application of the instrument could assist clinicians in detecting physical child abuse cases among pediatric trauma patients.

Age Factors↗
PubMed2002

The importance of coded radiographic labelling in clinical practice.

Locating a particular radiograph from a radiographic envelope can be a frustrating and time-consuming process. The aim of this study was to evaluate the role of colour and number coding of radiographs in reducing time taken to locate films and thereby improve efficiency. The time taken by clinicians to retrieve films from a radiographic envelope was measured. The radiographs were coded by number, number and colour or not at all. Results show a statistically significant reduction in time taken to find number coded versus non-coded radiographs. A further benefit was gained by using colour coding in conjunction with number coding. We recommend the use of colour and number coding of radiographs in clinical practice.

Forms and Records Control↗