Audit Of Clinical Coding Of Cataract- Related Procedures

The Office of Population Consensus and Surveys Classification of Intervention and Procedures, 4th revision (OPCS-4) is used in clinical coding of hospital procedures performed in the National Health System. These codes, in conjunction with diagnostic codes, are grouped to generate a Healthcare Resource Groups (HRG) code, which correlates to a national tariff. This audit aimed to assess the accuracy of data coded by the coding team on cataract-related procedures, and the impact on remuneration.

The Western Eye Hospital, London, United Kingdom.

Fifty cataract-related procedures performed over a 1-month period (1st to 30th September 2023) were chosen randomly and reviewed retrospectively. OPCS-4 codes recorded by professional hospital coders were compared with codes assigned by members of the Ophthalmology surgical team alongside with the head of clinical coding. The assigned HRG codes were compared to determine if there was any financial difference.   

An estimated 6000 cataract related procedures are carried out annually in our Trust. Of the 50 cases reviewed in this audit, common areas of missed coding included goniosynechialysis, examination under anaesthesia, corneal suturing, intracameral injection of miotic/mydriatic agents and vision blue. Incorrect codes were used in secondary intraocular lens implantation and removal of lens fragment. 28 (56%) had the same OPCS-4 and HRG codes allocated by both groups. Three (6%) cases had different OPCS-4 codes recorded but the HRG codes remained unchanged, therefore generating the same tariff. Nineteen (38%) cases had different OPCS-4 and HRG codes generated. This resulted in an estimated £736,680 annual theoretical loss of payment.

Clinical coding needs to be accurate and reproducible. The quality of coding can be improved by ensuring all relevant procedure steps are documented clearly by the surgical team. In addition, collaboration between coders and the ophthalmology team, such as holding regular coding audits, can ensure coding is accurate.