Payment by results data assurance framework

Transcription

1 ` Payment by results data assurance framework Report on the local audit programme for Surrey and Sussex Healthcare NHS Trust May 2013

2 For the 2012/13 PbR data assurance programme reporting on local work for NHS Surrey PCT cluster and also NHS Sussex PCT cluster will comprise a single report covering all work undertaken on behalf of each cluster. This document is an extract of that report and covers all audit work undertaken at Surrey and Sussex Healthcare NHS Trust. It is being made available prior to the production of the cluster report to provide feedback to the Trust on the findings of the audit work. An action plan has been included at the end of this report for the Trust to complete. The technical appendices and error examples have also provided separately.

3 Contact details: Linda Theobald Mobile: Document details: Authors: Owner: Client: Release Type: Release Date: Linda Theobald Peter Saunders Audit Commission DRAFT Distributed for Review This document has been distributed for the following to review: Name Organisation Issue Date Revision QA Capita Revision History Date of this revision: Revision Date Revision Number Author Summary of Changes Changes Marked Capita Business Services Limited 2013 On behalf of the Audit Commission The Statement of Responsibilities of Auditors and Audited Bodies issued by the Audit Commission explains the respective responsibilities of auditors and of the audited body. Reports prepared by appointed auditors are addressed to non-executive directors, members or officers. They are prepared for the sole use of the audited body. Auditors accept no responsibility to: any director/member or officer in their individual capacity; or any third party.

4 4 Contents INTRODUCTION...5 Background...5 The local audit programme...5 The Audit Commission...6 OBSTETRICS IN ADMITTED PATIENT CARE...8 Audit approach...8 Audit findings...8 Breakdown of errors...10 Unsafe to audit - cases excluded from the audit...11 Recommendations...12 MUSCULOSKELETAL DISORDERS IN ADMITTED PATIENT CARE...13 Audit approach...13 Audit findings...13 Breakdown of errors...15 Unsafe to audit - cases excluded from the audit...16 Recommendations...17 OBSTETRICS IN OUTPATIENTS...19 Audit approach...19 Audit findings...20 Breakdown of errors...21 Unsafe to audit - cases excluded from the audit...23 Recommendations...24 CLINICAL PHYSIOLOGY IN OUTPATIENTS...25 Audit approach...25 Audit findings...26 Breakdown of errors...27 Unsafe to audit - cases excluded from the audit...28 Recommendations...29 APPENDIX 1: PBR DATA ASSURANCE PROGRAMME ACTION PLAN 2012/ Obstetrics in admitted patient care...30 Musculoskeletal disorders in admitted patient care...30 Obstetrics in outpatients...31 Clinical physiology in outpatients...31

5 5 INTRODUCTION Background 1. For the past six years the Payment by Results (PbR) data assurance framework has provided assurance over the quality of the data that underpin payments as part of PbR, promoting improvement in data quality and supporting the accuracy of payment within the NHS. 2. In March 2012 the Audit Commission set out the framework s programme for 2012/13 1. This year s work will focus on both local and national assurance by: a. providing a flexible audit resource to commissioners to deliver local audit programme focused on specific areas of local risk to PbR data quality; and b. supporting tariff development and implementation by undertaking national data quality reviews of PbR in mental health and best practice tariffs. 3. The assurance framework s 2012/13 work programme has been developed and delivered by the Audit Commission s business partner, Capita Business Services Limited. The Commission s team responsible for developing and delivering the assurance framework for the past six years has transferred to Capita and all local audit work will be undertaken by Capita staff. The Audit Commission remains responsible and accountable for the overall assurance framework. 4. Details of the Audit Commission s work can be found at: The local audit programme 5. This report describes the findings from the local audit programme for Surrey and Sussex Healthcare NHS Trust. The local audit work draws on audit approaches developed and applied under previous years of the framework. 6. Each PCT cluster has been allocated a resource to be managed at a cluster level. This audit resource has been targeted on areas of risk identified by the cluster. This could be at one or many providers, use a trust wide audit sample or focus on one specific area of treatment. 7. The options we gave to the PCT cluster were: a. admitted patient care - clinical coding audits and the data items that drive payment; 1 Payment by Results Data Assurance Framework 2012/13: Improving the quality of contracting and commissioning data, Audit Commission, March 2012

6 6 b. outpatients attendance review including procedure coding and other data items that drive payment; and c. accident and emergency data items that drive payment. 8. Clusters have been provided with risk profiles to help inform the local programme these profiles combine comparative analysis from the National Benchmarker 2 and previous audit results. SUS continues to be the source of data for all aspects of the local audit programme. 9. We will also report our findings to each PCT as they are the statutory body responsible for commissioning this work. The Audit Commission 10. The Audit Commission is a public corporation set up in 1983 to protect the public purse. 11. The Commission appoints auditors to councils, NHS bodies (excluding NHS foundation trusts), local police bodies and other local public services in England, and oversees their work. 12. We also help public bodies manage the financial challenges they face by providing authoritative, unbiased, evidence-based analysis and advice. 2 The Audit Commission s national benchmarker is freely available to the NHS. To request a log-in go to

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8 8 OBSTETRICS IN ADMITTED PATIENT CARE Audit approach 13. Admitted patient care data in obstetrics from September to November 2012 was audited at Surrey and Sussex Healthcare NHS Trust. The sample comprised spells for HRGs sub chapter NZ. 14. The audit covered the Trust s clinical coding using the Connecting for Health (CFH) Audit Methodology v6, as well as the accuracy of other data items that affect the price commissioners pay for a spell under PbR: age on admission, admission method, sex, and length of stay. For each of these data items the information in SUS was verified against information in source documentation. 15. All errors have been agreed and signed off by the Trust. Audit findings 16. In the sample audited, the Trust had 7.9 per cent of spells with an error that affected the price. This means that 7.9 per cent of spells had either a clinical coding error affecting the HRG or a data entry error (or both). Both types of error result in the PCT being charged the price for that spell. If all the errors are added together there is a gross financial error of 1, The commissioner was undercharged by 1,200 for the errors in the audit sample. Table 1 below summarises the main findings. 3 The gross financial change is the total value of the spells that had errors, whether in favour of the provider or the PCT.

9 9 Table 1: Audit results and their financial impact for obstetrics in admitted patient care Episodes in audit sample 41 Spells tested 39 % spells changing payment 7.9 Pre audit payment 4 72,337 Post audit payment 73,537 Gross change 1,200 % gross change 1.7 Net change 5 1,200 % net change 1.7 Episodes unsafe to audit The performance of the Trust, measured against the number of spells with an payment, would place the Trust worse than average but not in the worst 25 per cent of trusts compared to last year s national performance. 18. We were provided with 41 episodes with a total value of 73,187. We could not audit 1 episode with a value of 850 because there was no evidence in the case notes or source documentation provided to support the data in SUS. We cannot therefore provide commissioners with assurance on these unsafe to audit (UTA) episodes. 4 The pre- and post-audit sample is priced using full PbR business rules but does not take local amendments into account such as market forces factor (MFF), non-payment for emergency readmissions, non-elective threshold, and any local agreements. 5 A negative figure represents an overcharge to the commissioner by the provider.

10 10 Breakdown of errors 19. Table 2 shows a breakdown of the audit results. Table 2: Full audit results for obstetrics in admitted patient care Clinical coding 6 Other data items Spells tested % of spells changing payment % of spells changing HRG % clinical codes % diagnoses Primary Secon dary % procedures Primary Secon dary % spells with other data items % other data items Table 3 outlines the main causes of error identified at the trust. Table 3: Clinical coding causes of error for obstetrics in admitted patient care % of causes of error in Causes of error 7 % of errors caused by spells changing payment Coder error Co morbidities and secondary codes Other Policy and procedures Software These figures contain all error types. The CFH clinical coding audit methodology excludes errors that are the inclusion of codes which are not relevant to the episode of care from the final audit figures. These errors can occur in four main areas: secondary diagnosis (co morbidities), external causes of injury, primary procedures and secondary procedures. These errors can have a direct impact on the assignment of HRGs and therefore payment. From this year we are including these errors in the coding error rate. The technical appendices of this document also contain the coding error rate calculated using the current CFH methodology. 7 Each error has been categorised into one of six areas: 1) coder error (a mistake by the coder relating to the process of clinical coding, such as not following the coding logic completely to identify the right code); 2) co morbidities and secondary codes (an error relating to the recording of co morbidities and other subsidiary codes, such as the inclusion of co morbidities that do not appear in the documentation for the episode being coded); 3) policy and procedures (local management or clinician specifications for coding that contravene national guidelines); 4) software (system constraints that impact on the codes that can be recorded, such as not being able to assign the 5 th character of a procedure or diagnosis code); 5) source documentation (errors related to the source documentation used for coding, such as the discharge summaries being the only source used for coding when more information was available in the case notes); and 6) other. The table in the appendix for this section provide a full breakdown of the different causes of error within each of the six categories.

11 11 Source documentation The obstetric case notes were well organised but complex. However, coders did not always review all the detailed paperwork. This resulted in coders omitting relevant codes. Coder also failed to follow national standards regarding the sequencing of codes in some instances. These types of errors caused payment changes in three spells. 22. In one case, surgical induction of labour unspecified (OPCS code R149) and medical induction of labour (OPCS code R151) were omitted but clearly stated in the notes. Correctly including these codes changed the HRG from NZ12C assisted delivery with epidural with complications to NZ12E assisted delivery with induction with complications; and the price increased from 2,182 to 2,287 after auditing. 23. In a second example the baby had a slow heartbeat that led to an instrumental delivery (OPCS code R149). Manual removal of placenta (OPCS code R291) was noted in the operation notes but was not coded. The mother also had a third stage haemorrhage (ICD code O720). Omission of these codes changed the HRG from NZ12F assisted delivery with induction without complications to NZ12G assisted delivery with post-partum surgical intervention. The overall price increased from 1,923 to 2, The third spell price change was caused because the surgical induction of labour was not coded. This caused the HRG to change from NZ11B normal delivery without complications to NZ11F normal delivery with induction without complications. The price increased from 1,066 to 1, In addition to reviewing clinical coding this year, we audited the accuracy of all data items that affect the price commissioners pay the Trust for a spell under PbR rules. We found no data item errors during the audit. Unsafe to audit - cases excluded from the audit 26. The aim of the programme is to provide assurance that the HRGs used as the basis for charging commissioners have been correctly calculated. We could not audit 1 of the 41 episodes in the audit sample (2.4 per cent) because they were unsafe to audit (UTA). 27. An episode is recorded as a UTA where there was insufficient or no information regarding the episode in the source documentation provided for audit or the auditor is unable to find any evidence to support the data in SUS. An FCE will not have more than one UTA. If an episode is a UTA it is excluded from the audit. In 2011/12 80 trusts had no UTAs. 28. This UTA had a financial value of 850 and was due to no information in the case notes that related to the episode of care due to be audited. 29. We cannot provide commissioners with assurance that this spell is correct as there was no evidence in the case notes or source documentation provided to support the coding undertaken.

12 12 Recommendations 30. Based on the audit completed we have made one recommendation to the Trust, which have been included in an action plan completed by the trust. The high priority recommendations is: report the findings of this audit to coders and ensure coders follow obstetric coding rules and national guidance. 31. The full action plan is included in the appendix.

13 13 MUSCULOSKELETAL DISORDERS IN ADMITTED PATIENT CARE Audit approach 32. Admitted patient care data in musculoskeletal disorders from September to November 2012 was audited at Surrey and Sussex Healthcare NHS Trust. The sample comprised spells for HRGs sub chapter HD musculoskeletal disorders. 33. The audit covered the Trust s clinical coding using the Connecting for Health (CFH) Audit Methodology v6, as well as the accuracy of other data items that affect the price commissioners pay for a spell under PbR: age on admission, admission method, sex, and length of stay. For each of these data items the information in SUS was verified against information in source documentation. 34. All errors have been agreed and signed off by the Trust. Audit findings 35. In the sample audited, the Trust had 10.0 per cent of spells with an error that affected the price. This means that 10.0 per cent of spells had either a clinical coding error affecting the HRG or a data entry error (or both). Both types of error result in the PCT being charged the price for that spell. If all the errors are added together there is a gross financial error of 2, The commissioner was undercharged by 2,418 for the errors in the audit sample. Table 4 below summarises the main findings. 8 The gross financial change is the total value of the spells that had errors, whether in favour of the provider or the PCT.

14 14 Table 4: Audit results and their financial impact for musculoskeletal disorders in admitted patient care Episodes in audit sample 68 Spells tested 58 % spells changing payment 10.0 Pre audit payment 9 41,103 Post audit payment 43,521 Gross change 2,628 % gross change 6.4 Net change 10 2,418 % net change 5.9 Episodes unsafe to audit The performance of the Trust, measured against the number of spells with an payment, would place the Trust in the worst performing 25 per cent of trusts compared to last year s national performance. 37. We were provided with 68 episodes with a total value of 48,270. We could not audit 8 episodes with a value of 7,167 because there was no evidence in the case notes or source documentation provided to support the data in SUS. We cannot therefore provide commissioners with assurance on these unsafe to audit (UTA) episodes. 9 The pre- and post-audit sample is priced using full PbR business rules but does not take local amendments into account such as market forces factor (MFF), non-payment for emergency readmissions, non-elective threshold, and any local agreements. 10 A negative figure represents an overcharge to the commissioner by the provider.

15 15 Breakdown of errors 38. Table 5 shows a breakdown of the audit results. Table 5: Full audit results for musculoskeletal disorders in admitted patient care Clinical coding 11 Other data items Spells tested % of spells changing payment % of spells changing HRG % clinical codes % diagnoses Primary Secon dary % procedures Primary Secon dary % spells with other data items % other data items Table 6 outlines the main causes of error identified at the trust. Table 6: Clinical coding causes of error for musculoskeletal disorders in admitted patient care % of causes of error in Causes of error 12 % of errors caused by spells changing payment Coder error Co morbidities and secondary codes Other Policy and procedures These figures contain all error types. The CFH clinical coding audit methodology excludes errors that are the inclusion of codes which are not relevant to the episode of care from the final audit figures. These errors can occur in four main areas: secondary diagnosis (co morbidities), external causes of injury, primary procedures and secondary procedures. These errors can have a direct impact on the assignment of HRGs and therefore payment. From this year we are including these errors in the coding error rate. The technical appendices of this document also contain the coding error rate calculated using the current CFH methodology. 12 Each error has been categorised into one of six areas: 1) coder error (a mistake by the coder relating to the process of clinical coding, such as not following the coding logic completely to identify the right code); 2) co morbidities and secondary codes (an error relating to the recording of co morbidities and other subsidiary codes, such as the inclusion of co morbidities that do not appear in the documentation for the episode being coded); 3) policy and procedures (local management or clinician specifications for coding that contravene national guidelines); 4) software (system constraints that impact on the codes that can be recorded, such as not being able to assign the 5 th character of a procedure or diagnosis code); 5) source documentation (errors related to the source documentation used for coding, such as the discharge summaries being the only source used for coding when more information was available in the case notes); and 6) other. The table in the appendix for this section provide a full breakdown of the different causes of error within each of the six categories.

16 16 Software Source documentation Many case notes were in poor condition and consequently difficult for coders to get the right information from them. The Trust s case note filing process is not always followed, with loose paperwork found in the case notes. Occasionally electronic discharge summaries only are used as the main coding source to meet the Trust s deadlines. Some discharge summaries had conditions recorded ly and co-morbidities omitted. 41. Badly organised case notes and discharge summaries were the behind most of the coding errors found in this audit. There were five spells with errors impacting the price. We also found clinical coding errors, particularly secondary diagnosis and secondary procedure errors. 42. In one case a patient s secondary diagnosis of left sided weakness after a stroke (ICD code G819) was not coded although this was stated in the case notes. After auditing, the HRG changed from HD26B musculoskeletal signs and symptoms with complications to HD26A musculoskeletal signs and symptoms with major complications. Omitting this code caused difference of 1,867 as the price increased from 1,242 to 3, In another example, a patient developed an infection following ankle surgery. This was omitted from coding although recorded in the notes as a post operative complication. This patient was also severely dehydrated and treated with intravenous fluids (ICD code E86X). These two secondary diagnoses coding omissions caused an HRG changed from HD21C soft tissue disorders without complications to WA12X complications of procedures with intermediate complications. The price changed from 358 to 577. The records noted that the patient was a smoker (ICD code F171), which is a mandatory co morbidity but was not coded. 44. Coding errors that did not impact on price changes were also mostly caused by poor source documentation and coder error, such as poor data extraction or not adhering to national standards. There were 28 codes that did not change the price; including 16 co morbidity or secondary diagnosis errors. 45. In addition to reviewing clinical coding this year, we audited the accuracy of all data items that affect the price commissioners pay the Trust for a spell under PbR rules. No data item errors were found during the audit. Unsafe to audit - cases excluded from the audit 46. The aim of the programme is to provide assurance that the HRGs used as the basis for charging commissioners have been correctly calculated. We could not audit 8 of the 68 episodes in the audit sample (11.8 per cent) because they were unsafe to audit (UTA). Table 7 summarises this.

17 17 Table 7: spells that were unsafe to audit in musculoskeletal disorders in admitted patient care Number of episodes with a UTA % of total audit sample Number of spells unsafe to audit Financial value of UTAs , An episode is recorded as a UTA where there was insufficient or no information regarding the episode in the source documentation provided for audit or the auditor is unable to find any evidence to support the data in SUS. An FCE will not have more than one UTA. If an episode is a UTA it is excluded from the audit. In 2011/12 80 trusts had no UTAs. 48. These UTAs had a financial value of 7,167 and were due to no information in the notes pertaining to the episode of care in seven sets of case notes because the case notes were in a poor condition. Discharge summaries are also used for coding occasionally and some were completely with very poor detail; conditions recorded ly and co-morbidities omitted. 49. We cannot provide commissioners with assurance that these spells are correct as there was no evidence in the case notes or source documentation provided to support the coding undertaken. Recommendations 50. Based on the audit completed we have made one recommendation to the Trust, which have been included in an action plan completed by the trust. The high priority recommendation is: improve the organisation and accuracy of coding source documentation, in particular case note organisation and discharge summary clinical information. 51. The full action plan is included in the appendix.

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19 19 OBSTETRICS IN OUTPATIENTS Audit approach 52. Outpatient data in obstetrics from quarter was audited at Surrey and Sussex Healthcare NHS Trust. The sample focused on the obstetrics sub chapter HD. 53. The audit covered the Trust s coding of outpatient procedures and the accuracy of other data items that affect the price commissioners pay for an outpatient attendance without a procedure. These other data items are: treatment function code, first/ follow up flag, age, and whether the attendance met the criteria of a PbR outpatient attendance. 54. This is the first year we have reviewed coding in outpatients. Outpatient procedure coding is not nationally mandated however procedure driven HRGs are now routinely used for payment under PbR. There are now 84 HRGs with a mandated outpatient tariff, and this covers approximately 75 per cent of procedures coded in outpatients. 55. To maintain consistency within the audit programme we have used the existing CFH audit methodology to review coding in outpatients. This approach provides two measures of data quality: a. HRGs changing tests whether a trust s coding is fit for purpose for payment; and b. procedure codes tests whether a trust is capturing all relevant procedure codes to accurately reflect the care that is delivered All errors have been agreed and signed off by the Trust. 13 Procedures includes secondary codes that provide additional information, such as the site (position on the body), laterality (side of the body), or the method of the operation (Y codes), which are required for complete and accurate coding but may not be routinely collected in an outpatient setting. This error rate also includes errors that reflect the inclusion of codes which are not relevant to the episode of care, which are excluded from the current CFH methodology but which can have a direct impact on the assignment of HRGs and therefore payment.

20 20 Audit findings 57. In the sample audited, the Trust had 15.0 per cent of attendances with an error that affected the price. This means that 15.0 per cent of attendances had either a coding error affecting the HRG of the outpatient procedure or a data entry error affecting the attendance details (or both). Both types of error result in the PCT being the price for that attendance. If all the errors are added together there is a gross financial error of The commissioner was under charged by 534 for the errors in the audit sample. Table 8 overleaf summarises the main findings. Table 8: Audit results and their financial impact for obstetrics in outpatients Attendances in audit sample 80 Attendances tested 87 % attendances changing payment 15.0 Pre audit payment 15 6,694 Post audit payment 7,228 Gross change 728 % gross change 10.9 Net change % net change 8.0 Attendances unsafe to audit We were provided with 87 attendances with a value of 7,320. We could not audit 7 attendances with a value of 626 because they were unsafe to audit (UTA). We cannot provide commissioners with assurance that these attendances are correct as there was no evidence in the case notes or source documentation provided to support the data in SUS. 14 The gross financial change is the total value of the spells that had PbR errors, whether in favour of the provider or the PCT. 15 The pre- and post-audit sample is priced using full PbR business rules but does not take local amendments into account such as market forces factor (MFF) and any local agreements. 16 A negative figure represents an overcharge to the commissioner by the provider.

21 21 Breakdown of errors 59. Table 9 shows a breakdown of the audit results. Table 9: Full audit results for obstetrics in outpatients Procedure coding Other data items Attendances tested % attendances changing payment Attendances with tariffed HRGs 17 % HRGs changing % procedure codes 18 % attended flag % first / follow % TFCs % age The performance of the Trust, measured against the number of attendances changing payment due to errors in attendance details (excluding the coding of procedures), would place the Trust better than average, but not in the top 25 per cent of trusts compared to the last time we undertook a national audit outpatient data ( ). 17 Outpatient attendances with a procedure that group to a HRG without a nationally mandated tariff are treated as an attendance without a procedure by the grouper. 18 If a trust is not recording procedures then the denominator for this figure will be low (number of procedure codes recorded). Where this is the case there is a possibility the % procedure codes could exceed 100%.

22 Table 10 outlines the main causes of procedure coding error identified at the Trust. Table 10: Procedure coding causes of error for obstetrics in outpatients Causes of error 19 Coder/ data entry error % of causes of error in attendances changing % of errors caused by payment Other Policy and procedures Software Source documentation The majority of errors and price changes resulted from coding or data entry errors where the main procedure code was omitted. Outcome forms are used to record the procedures and the data is then entered onto the Trust system from these. They were not available during for the audit because they were normally destroyed. So we cannot confirm if errors were due procedures not being captured on the outcome form or poor data entry not inputting information that was recorded on the outcome forms. 63. Three examples show the impact of not correctly recording the procedures carried out in an outpatient setting. The information about the procedures was documented in the case notes. 64. In one cases, an ultrasound scan (OPCS R369) and the related gestational code (OPCS code Y951) were omitted. In correcting these errors, the HRG changed from a follow-up attendance to NZ05C antenatal or postnatal investigation between 16 and 40 year with length of stay 0 days; and the price changed from 60 to When a membrane sweep (OPCS code R128) was omitted, this changed the HRG from a follow-up attendance to NZ05C antenatal or postnatal investigation between 16 and 40 year with length of stay 0 days; and the price increased from 60 to Each procedure error has been categorised into one of five areas: 1) coding/ data entry error (a mistake by the coder or person undertaking the data entry, such as an omission of a code for a procedure that appears in the source documentation); 2) policy and procedures (local specifications for coding or data capture that lead to data being recorded); 3) software (system constraints that impact on the codes that can be recorded, or issues with how the software has been set-up to record the information); 4) source documentation (errors related to the source documentation used, such as the outcomes forms being the only source used for coding when more information was available in the case notes); and 5) other. The table in the appendix for this section provide a full breakdown of the different causes of error within each of the five categories.

23 In a third example, the injection of rhesus immune globulin (OPCS code X301) was omitted. In correcting these errors, the HRG changed from follow-up attendance to SA13A single plasma exchange with length of stay 2 days or less and 19 years or over. This changed the price from 60 to In some cases treatments were coded in error, although they were not recorded. In one example, other maternal physiological assessments (OPCS code R408) was coded although there was no mention of this in the notes. This changed the HRG from NZ05C antenatal or postnatal investigation between 16 and 40 year with length of stay 0 days to follow up attendance. The price reduced from 119 to 60 in this instance. 68. There was one data item error where the expectant mother had previously been seen by both midwife and consultant. This was recorded as a first attendance when it should have been a follow up attendance. Unsafe to audit - cases excluded from the audit 69. There were no attendances that were unsafe to audit in the audit sample. 70. The aim of the programme is to provide assurance that the HRGs used as the basis for charging commissioners have been correctly calculated. We could not audit 7 of the 87 attendances in the audit sample (8.0 per cent) because they were unsafe to audit (UTA). Table 11 summarises this. Table 11: Attendances that were unsafe to audit in obstetrics in outpatients Number of attendances with a UTA Financial value of UTAs An attendance is recorded as a UTA where there was insufficient or no information regarding the attendance in the source documentation provided for audit or the auditor is unable to find any evidence to support the data in SUS. An attendance will not have more than one UTA. If an attendance is a UTA it is excluded from the audit. 72. These UTAs had a financial value of 626 and were due to expectant mothers retaining their own notes and relevant information not duplicated in the case notes provided for audit. Seven of these cases were deemed unsafe to audit because of this. 73. We cannot provide commissioners with assurance that these attendances are correct as there was no evidence in the case notes or source documentation provided to support the coding undertaken.

24 24 Recommendations 74. Based on the audit completed we have made two recommendations to the Trust, which have been included in an action plan completed by the trust. The high priority recommendations are: ensure outcome forms are completed accurately and data is entered onto the Trusts system accurately; and, audit a sample of outpatient attendances regularly to make sure procedures are recorded accurately. 75. The full action plan is included in the appendix.

25 25 CLINICAL PHYSIOLOGY IN OUTPATIENTS Audit approach 76. Outpatient data in clinical physiology from quarter was audited at Surrey and Sussex Healthcare NHS Trust. The sample focused on the clinical physiology with HRG EA47Z electrocardiogram monitoring and stress testing selected. 77. The audit covered the Trust s coding of outpatient procedures and the accuracy of other data items that affect the price commissioners pay for an outpatient attendance without a procedure. These other data items are: treatment function code, first/ follow up flag, age, and whether the attendance met the criteria of a PbR outpatient attendance. 78. This is the first year we have reviewed coding in outpatients. Outpatient procedure coding is not nationally mandated however procedure driven HRGs are now routinely used for payment under PbR. There are now 84 HRGs with a mandated outpatient tariff, and this covers approximately 75 per cent of procedures coded in outpatients. 79. To maintain consistency within the audit programme we have used the existing CFH audit methodology to review coding in outpatients. This approach provides two measures of data quality: a. HRGs changing tests whether a trust s coding is fit for purpose for payment; and b. procedure codes tests whether a trust is capturing all relevant procedure codes to accurately reflect the care that is delivered All errors have been agreed and signed off by the Trust. 20 Procedures includes secondary codes that provide additional information, such as the site (position on the body), laterality (side of the body), or the method of the operation (Y codes), which are required for complete and accurate coding but may not be routinely collected in an outpatient setting. This error rate also includes errors that reflect the inclusion of codes which are not relevant to the episode of care, which are excluded from the current CFH methodology but which can have a direct impact on the assignment of HRGs and therefore payment.

26 26 Audit findings 81. In the sample audited, the Trust had 11.3 per cent of attendances with an error that affected the price. This means that 11.3 per cent of attendances had either a coding error affecting the HRG of the outpatient procedure or a data entry error affecting the attendance details (or both). Both types of error result in the PCT being the price for that attendance. If all the errors are added together there is a gross financial error of The commissioner was overcharged by 45 for the errors in the audit sample. Table 12 below summarises the main findings. Table 12: Audit results and their financial impact for clinical physiology in outpatients Attendances in audit sample 80 Attendances tested 80 % attendances changing payment 11.3 Pre audit payment 22 11,600 Post audit payment 11,555 Gross change 435 % gross change 3.8 Net change % net change -0.4 Attendances unsafe to audit 0 21 The gross financial change is the total value of the spells that had PbR errors, whether in favour of the provider or the PCT. 22 The pre- and post-audit sample is priced using full PbR business rules but does not take local amendments into account such as market forces factor (MFF) and any local agreements. 23 A negative figure represents an overcharge to the commissioner by the provider.

27 27 Breakdown of errors 82. Table 13 shows a breakdown of the audit results. Table 13: Full audit results for clinical physiology in outpatients Procedure coding Other data items Attendances tested % attendances changing payment Attendances with tariffed HRGs 24 % HRGs changing % procedure codes 25 % attended flag % first / follow % TFCs % age The performance of the Trust, measured against the number of attendances changing payment due to errors in attendance details (excluding the coding of procedures), would place the Trust in the best performing 25 per cent of trusts compared to the last time we undertook a national audit outpatient data ( ). 84. Table 14 outlines the main causes of procedure coding error identified at the Trust. Table 14: Procedure coding causes of error for clinical physiology in outpatients Causes of error 26 % of errors caused by % of causes of error in attendances changing payment Coder/ data entry error Other Policy and procedures Software Outpatient attendances with a procedure that group to a HRG without a nationally mandated tariff are treated as an attendance without a procedure by the grouper. 25 If a trust is not recording procedures then the denominator for this figure will be low (number of procedure codes recorded). Where this is the case there is a possibility the % procedure codes could exceed 100%. 26 Each procedure error has been categorised into one of five areas: 1) coding/ data entry error (a mistake by the coder or person undertaking the data entry, such as an omission of a code for a procedure that appears in the source documentation); 2) policy and procedures (local specifications for coding or data capture that lead to data being recorded); 3) software (system constraints that impact on the codes that can be recorded, or issues with how the software has been set-up to record the information); 4) source documentation (errors related to the source documentation used, such as the outcomes forms being the only source used for coding when more information was available in the case notes); and 5) other. The table in the appendix for this section provide a full breakdown of the different causes of error within each of the five categories.

28 28 Source documentation All the payment errors were caused by coding procedures that did not take place. There were nine attendances where errors impacted upon the price because electrocardiography was coded but was not recorded in the records. Diagnostic electrocardiography (OPCS U199); exercise electrocardiography (OPCS U194) had been recorded but did not take place. 86. In three cases after correcting the errors, the HRG changed from WA47Z ECG monitoring and stress testing to WF01B face to face first attendance and the price increased from 145 to 210. ECGs were also recorded in error where the HRG changed from ECG monitoring to WFA47A face to face follow up attendance and the price decreased from 145 to 105. This happened on six occasions. 87. There was no record of any ECG performed on the date of the attendance in six of these case notes. Three ECGs were planned for future dates, but it was not clear if these investigations were coded and charged again when they actually took place. The Trust should review its processes for logging planned investigations and ensure the commissioner is not charged. Unsafe to audit - cases excluded from the audit 88. There were no attendances that were unsafe to audit in the audit sample.

29 29 Recommendations 89. Based on the audit completed we have made two recommendations to the Trust, which have been included in an action plan completed by the trust. The high priority recommendations are: review the processes for logging planned investigations. Check that the planned investigations found in this audit did not incur duplicate charges to the commissioners when the investigations were performed; and ensure that procedures are correctly specified on cardiology outcome forms. 90. The full action plan is included in the appendix.

30 30 APPENDIX 1: PBR DATA ASSURANCE PROGRAMME ACTION PLAN 2012/13 Obstetrics in admitted patient care Recommendation 1 Responsibility Priority Date Comments Report the findings of this audit to coders; in particular, remind coders of the obstetrics coding rules and national guidance. Name and job title - to be completed by Trust High Target date for completion: month year - to be completed by Trust Any further comments from Trust, including progress since audit Musculoskeletal disorders in admitted patient care Recommendation 2 Responsibility Priority Date Comments Improve the organisation and accuracy of coding source documentation, in particular case note organisation and discharge summary clinical information. Consider adopting the Royal College of Physicians medical record keeping standards. Name and job title - to be completed by Trust High Target date for completion: month year - to be completed by Trust Any further comments from Trust, including progress since audit

31 31 Obstetrics in outpatients Recommendation 3 Responsibility Priority Date Comments Ensure outcome forms are completed accurately and data is entered onto the Trusts system accurately. Name and job title - to be completed by Trust High Target date for completion: month year - to be completed by Trust Any further comments from Trust, including progress since audit Recommendation 4 Responsibility Priority Date Comments Audit a sample of outpatient attendances regularly to make sure procedures are recorded accurately. Name and job title - to be completed by Trust High Target date for completion: month year - to be completed by Trust Any further comments from Trust, including progress since audit Clinical physiology in outpatients Recommendation 5 Responsibility Priority Date Comments Review the processes for logging planned investigations. Check that the planned investigations found in this audit did not incur duplicate charges to the commissioners when the investigations were performed. Name and job title - to be completed by Trust High Target date for completion: month year - to be completed by Trust Any further comments from Trust, including progress since audit

32 32 Recommendation 6 Responsibility Priority Date Comments Ensure that investigations are correctly specified on cardiology outcome forms, particularly the type of ECG performed. Name and job title - to be completed by Trust High Target date for completion: month year - to be completed by Trust Any further comments from Trust, including progress since audit