CLINICAL CODING POLICY AND PROCEDURE

A University Teaching Trust CLINICAL CODING POLICY AND PROCEDURE This Policy describes good practice and consistency of information produced during the clinical coding process in LPT. This document should be used by the clinical coding team to document coding policy and procedures within the trust, which have been agreed with personnel involved in the coding process, including relevant clinicians. Key Words: Version: Adopted by: CLINICAL CODING; ICD-10; National Classification V2.0 Final QAC Date adopted: June 2014 Name of originator/author: Name of responsible committee: Date issued for publication: Kim Dawson Records and Information Governance Group June 2014 Review date: May 2015 Expiry date: November 2015 Target audience: Clinicians Type of Policy (tick appropriate box) NHSLA Risk Management Standards if applicable: State 00Relevant CQC Standards: Clinical x Non Clinical 05/12/2013 Page 1 of 27

CONTRIBUTION LIST Key individuals involved in developing the document Name Sam Kirkland Rinku Sakariya Deborah Lavender Ramesh Raithatha Julie West Dr Graeme Whitfield Designation Records Transformation & Information Governance Manager Contract Clinical Coder and Auditor Clinical Coder Clinical Coder Clinical Coder Consultant Circulated to the following individuals for comments Name LPT Records and Information Governance Group Divisional Information Governance & Health Records Groups Designation All Members All Members of FYPC/AMH&LD and CHS Groups 05/12/2013 Page 2 of 27

Contents Definitions 6 Equality Statement 7 1.0 Summary 7 2.0 Introduction 7 3.0 Scope 7 4.0 Statement of Purpose 8 5.0 Duties and Responsibilities 8 5.1 Medical Director and Clinical Directors 8 5.2 Consultants, SpRs/Staff Grades/SHO s 9 5.3 Clinical Coding Manager 9 5.4 Clinical Coders 9 6.0 Clinical Coding Procedures 9 6.1 Source Document 9 6.2 Point of Coding 10 6.2.1 Mental Health 10 6.2.2 Community 10 6.2.3 Day Case Coding 10 6.2.4 Community Inpatient Coding 10 6.3 Timescales 11 6.3.1 Mental Health Reporting 11 6.3.2 Community Reporting 11 6.4 Validation of Clinical Coded Information 11 6.4.1 Internal Audits 12 6.4.2 External Audits 12 6.4.3 Audit Methodology 12 6.4.4 Corrections of Errors 13 6.4.5 Implementation of Changes 13 6.4.6 Internal Quality Assurance Measures 13 6.5 Communications in Clinical Coding 13 7.0 Structure of Clinical Coding Department 13 05/12/2013 Page 3 of 27

8.0 Management and Training 14 8.1 Induction programme for New Starters 15 8.2 Experienced Coders 15 8.3 Training for Non-Coding Staff 16 9.0 Security and Confidentiality 16 10.0 Due Regard 17 11.0 Monitoring Compliance 17 11.1 Audit and Outcomes 17 11.2 Process for Monitoring Compliance 17 12.0 Review 18 12.1 Archiving 18 13.0 References 18 Appendix A Key Guidance Documents 20 Appendix B National/Regional Clinical Coding Query Service Proforma 22 Appendix C Policy Monitoring Form 24 Appendix D Policy Training Form 25 Appendix E Due Regard Screening 26 05/12/2013 Page 4 of 27

Version Control and Summary of Changes Version number Date Comments (description change and amendments) 1.0 21/12/2012 Frist Draft 2.0 02/05/2013 Second draft following extensive comments and amendments 2.0 09/07/2013 Approved by Records and Information Governance Group and to be forwarded to Policy Group 2.0 05/12/2013 Supported by Policy Group All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them. Did you print this document yourself? Please be advised that the Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. 05/12/2013 Page 5 of 27

Definitions that apply to this Policy Clinical Coding Co-morbidities ICD-10 Primary Diagnosis Mental Health Minimum Data set Clinical Coding is the translation of medical Terminology that describes a patients complaint, problem, treatment or other reasons for seeking medical attention into codes that can then be easily tabulated, aggregated and sorted for statistical analysis in an efficient and meaningful manner Any condition which co-exists in conjunction with another disease that is currently being treated at the time of admission or develops subsequently. That affects the management of the patients current episode ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [ The main condition treated or investigated during the relevant episode of healthcare The Mental Health Minimum Data Set facilitates the collection of personfocussed clinical data and the sharing of such data to underpin the delivery of mental health care. It is structured around the clinical process and includes an outcome assessment (Health of the Nation Outcome Scale (Working Age Adults), or HoNOS (Working Age Adults)). It records the key role played by partner agencies, particularly social services. OPCS-4 In UK health care, OPCS Classification of Interventions and Procedures (OPCS-4) is a procedural classification for the coding of operations, procedures and interventions performed during in-patient stays, day case surgery and some out-patient attendances in the National Health Service (NHS). Responsibility for revision and maintenance is currently with NHS Connecting for Health (NHS CFH). Payment by Results Payment by Results (PbR) is the transparent rules-based payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient s healthcare needs. PbR promotes efficiency, supports patient choice and increasingly incentivizes best practice models of care. Due Regard Having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics. Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. 05/12/2013 Page 6 of 27

Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation. 1.0 Summary The purpose of this document is to promote good practice and consistency of information being produced through clinical coding processes within Leicestershire Partnership NHS Trust (LPT). It has also been designed to ensure information produced during the coding process is accurate and adheres to local and national policies. Accurate clinical record keeping underpins accurate clinical coding. Clinical coders rely on medical staff to accurately document the main condition and other conditions relevant to an episode of care. Finished Consultant Episodes with missing, inconsistent or incorrectly recorded main conditions will be investigated and clarified by the Trust s trained clinical coders. 2.0 Introduction This document has been published with the intention of promoting good practice and consistency of information produced during the clinical coding process in LPT. It has also been designed to incorporate the requirements of the Data Accreditation process to ensure information produced during the coding process is accurate and adheres to local and national policies. This document should be used by the clinical coding team to document coding policy and procedures within the trust, which have been agreed with personnel involved in the coding process, including relevant clinicians. 3.0 Scope This policy details the procedures regarding the clinical coding of all Clinical care. It outlines the responsibilities of clinical and administrative staff and the timescales in which coding should be completed. This policy is for use by all Trust staff involved in the coding of patient activities and should be read in conjunction with the Trust s Information Lifecycle and Records Management Policy and Data Quality Policy, available on trusts intranet. www.leicspart.nhs.uk 05/12/2013 Page 7 of 27

4.0 Statement of purpose The purpose of this document is to promote good practice and consistency of information being produced through clinical coding processes within LPT. It has also been designed to ensure information produced during the coding process is accurate and adheres to local and national policies. 4.1 To provide accurate, complete, timely coded clinical information to support commissioning, local information requirements and the information required for Commissioning Minimum Data Set (CMDS) and Central Returns on behalf of the Trust represented by the clinical coding department. 4.2 To adhere to national standards and classification rules and conventions as set out in the WHO ICD-10 Volumes 1-3, Clinical Coding Instruction Manual 4.3 To input onto the NHS hospital computer system, such as the Patient Administration System (PAS,) accurate and complete coded information within the designated time scales to support the information requirements and commissioning of the Hospital Trust. 4.4 To provide accurate, consistent and timely information to support clinical governance and the Data Accreditation process. 4.5 To ensure all staff involved in the clinical coding process receive regular training to maintain and develop their clinical coding skills, regardless of experience and length of service. 4.6 To ensure continual improvement of clinical coded information within the Trust through systematic audit and quality assurance procedures. 4.7 To ensure all staff are aware of the Trust s security and confidentiality policies when using patient identifiable information. 5.0 Duties and Responsibilities The responsibility for the adoption of the policy and procedure and its enforcement belongs to the Chief Executive of the Trust. To assist the Chief Executive with the discharge of this responsibility, the Records Transformation and Information Governance Manager has been delegated lead responsibility for developing and implementing this procedure. 5.1 Medical Director and Clinical Directors (across mental health division s / day case basket and community beds) To raise awareness and support the new process for obtaining diagnosis and to convert into an ICD-10 code. To emphasise the need for, the medical team to give a Primary and Secondary diagnosis including any relevant co morbidities pertains to the episode of care as outlined in Clinical coding instruction manual /coding clinical August 2012 [v2.2] 05/12/2013 Page 8 of 27

5.2 Consultants, SpR s/staff Grades and SHO s Medical staff must document accurate clinical information and assign primary diagnosis codes. The majority of ICD-10 codes use 4 th character, and this must be included or will automatically default to 9 5.3 Clinical Coding Manager The Clinical Coding Manager will ensure that the systems and processes for capturing and monitoring coding activity is fit for purpose and supports the patients journey. Manage the validation programme to support clinicians in accurate coding of clinical information Undertake a programme of internal audits to ensure compliance with coding conventions and in preparation for the annual CfH Information Governance Toolkit Clinical Coding Audit. Ensure that clinical coding staff have undertaken appropriate training and remain up to date. 5.4 Clinical Coders It is the clinical coder s responsibility for capturing all relevant diagnoses with ICD-10 and OPCS 4.6 codes for a patient s episode of care.to the highest degree of specification, in line with the rules, conventions and national standards as set out in clinical coding instruction manuals. Using the four step coding process. Clinical Coders will verify codes and agree amendments with medical staff. Clinical Coders will assign secondary diagnosis codes and any OPCS-4 codes. Clinical Coders will assign primary diagnosis codes where these have been omitted from a Finished Consultant Episode (FCE). This will be obtained from information provided in the patient s records within 48 hours of patients discharge. For any missing diagnosis, the relevant Consultant responsible for that episode of care will be contacted for a diagnosis. 6.0 Clinical Coding Procedures 6.1 Source Document The DH recommends the use of the medical notes, as this source document contains all the relevant information about the patient s hospital stay. In LPT the following source documents are used to record an accurate clinical picture of the patient s diagnosis, problem or other reason for a hospital stay: 05/12/2013 Page 9 of 27

Inpatient summary letter/discharge TTO letter (available via e-prescribing and Anglia ICE) Clinical notes Operative notes Histopathology/microbiology report (available via I Lab) Nursing Notes Endoscopy reports (available via Unisoft) GP letters, CPA s The information in the medical notes should be clearly documented in line with the Trust s Information Lifecycle Management including Records Management Policy and the guidelines of relevant professional associations. It is the responsibility of all staff using medical notes to ensure the information in them is accurate and up-todate. 6.2 Point of Coding Leicestershire Partnership Trust provides an integrated service to mental health and community resulting in devolved clinical coding function. 6.2.1 Mental Health The coding process is usually instigated on the day of discharge. As far as possible, all coding will be done on the wards or remotely from discharge summaries. Coders also visit Medical secretaries. 6.2.2 Community In the community the following specialities are covered Day cases which includes: Gynaecology, Orthopaedic, Endoscopic procedures, General surgery & Plastic surgery. Community also covers elderly inpatients. Data is taken from a number of source documents. Community coder s refer to daily report status to ascertain incomplete coding. 6.2.3 Day Case coding When possible, information is gathered from source documents i.e. patient paper record. Where this is not always practical due to quick return of patients for clinic appointments, electronic records are used to gather data. Electronic held information: Ormis (theatre production) information in putted by clinician Ilab (Histology, pathology results/reports) Ecris (Scan, radiological procedures) 6.2.4 Community inpatient Coding When possible the source document i.e. patients paper record should be used. But due to locality and increasing numbers of patient transfers, this is not always 05/12/2013 Page 10 of 27

possible.coders in the absence of notes will access electronic summary which holds sufficient information relevant to episode to code from. 6.3 Time Scales 6.3.1 Mental Health Reporting Local reporting: The following are reported in the Divisional scorecards: % of ICD10 Coding Complete - FCE's Primary Diagnosis % of ICD10 Coding Complete - Open CMHT, Outpatient & Day-care cases The deadline for this information for a month is the last day of the month. National reporting: There is a monthly submission of HES (Hospital Episode Statistics) made to SUS (Secondary User Service) every month on the 10th of each month. The period submitted is a rolling 3 months period. E.g. April/May/June is submitted on 10/07/2014 May/June/July are submitted on 10/08/2014 and so on. The MHMDS deadlines are as below: Year/Quarter Deadline Q1 Q2 and Q1R Submission Mid-August Early November During the course of the year submissions move from a quarterly to a monthly submission so that monthly submissions are established by April 2014. This is to support Payment by Results for mental health. Further information about the process for submitting data via the Bureau Service Portal can be found in Section C of the MHMDS version 4 User Guidance. 6.3.2 Community reporting Community reporting Community Clinical coding is based upon a 14 day calendar target post discharge. All community clinical coders have access to online reports which are available 24/7 and updated daily displaying uncoded items for all elective and non-elective discharges All community discharges (both elective and non-elective) are run through the HRG local payment grouper daily to generate a HRG code 6.4 Validation of Clinical Coded Information All clinical coders are encouraged to seek clinical opinion to review the health records of any episodes that they may have difficulty coding. It is usual for clinical coder to send a query to the clinician via email or meet in person. 05/12/2013 Page 11 of 27

Monthly reports are sent to the responsible consultant for the validation of primary diagnosis in mental health. This usually involves the clinical coder producing a report from an electronic source, adding primary diagnosis.the clinician and coder usually meet monthly to discuss previous month s inpatients coding. Any discrepancies are signed off by clinician and corrected by coder. Validation paper work is stored by Clinical Coding Manager for further trend analysis. 6.4.1 Internal Audits Under taken by clinical coding manager from a random sample of 50 case notes Further development work on internal audit is under development. Where electronic documentation is used as source data this is audited against paper documentation noting any discrepancies. 6.4.2 External Audits External audits are undertaken once a year on a sample of at least 200 clinical records (As per Requirement 516 of the IG Toolkit www.igt.connectingforhealth.nhs.uk). 6.4.3 Audit Methodology The Clinical Coding Audit Methodology version 6.0 describes the full range of analyses that are carried out on all diagnosis and procedure codes. These include the analysis of primary and secondary diagnosis and procedure codes, for correct and incorrect codes, incorrect sequencing of codes, irrelevant codes and omitted codes. The coding audit also examines the process undertaken for coding and the source documentation available to clinical coders during the coding process. The audit must include a minimum of 200 case notes or 2% of the total Finished Consultant Episodes (whichever the lesser) and should be representative of the case mix and admission type (e.g. Inpatient to day case ratio) A full copy of the audit report is required to be sent to the NHS Classifications Service. This is to promote good practice in the analysis of issues and trends and to ensure that issues that are best addressed nationally can be flagged up. The NHS Classifications Service has recommended the following percentage accuracy scores as targets: Level of Attainment: Level 2 Level 3 Primary Diagnosis >= 90% >=95% Secondary Diagnosis >= 80% >=90% Primary Procedure >= 90% >=95% Secondary Procedure >= 80% >=90% Evidence that the recommendations made in the previous clinical coding audits are found to have been noted and actioned. 05/12/2013 Page 12 of 27

6.4.4 Correction of Errors All errors identified as a result of audit are to be corrected within one month. 6.4.5 Implementation of Changes The Clinical Coding Manager is responsible for implementing any changes in coding Practice as a result of audit or other means. All changes must be documented, and the Clinical Coding Manager will ensure that the coding team are aware of and implement the changes. 6.4.6 Internal Quality Assurance Measures The Clinical Coding Manager will demonstrate evidence of close supervision of staff undertaking the coding process (e.g. regular audit of Individual Coder) to assess consistency and accuracy, completing and signing of forms by the coding staff to acknowledge changes/alterations in coding practice and regular review of coding standards. 6.5 Communications in Clinical Coding The Team has arrangements in place for the receipt and dissemination of relevant documentation relating to clinical coding across the Trust to endorse consistency and accuracy of coded information. The following steps are included: National Clinical Coding Standards ICD-10 4th Edition, Clinical Coding Instruction Manual OPCS 4.6, Coding Clinic Collection and NHS Connecting for Health s clinical coding guidelines. Liaison with appropriate clinician on applicable ICD10 and OPCS4 codes. This is usually done through e-mail. Clinical coders ensure that the advice given does not contravene the rules and conventions of the classifications or national standards. Standards agreed with clinicians are documented appropriately. Reference to coding manager to determine whether the query can be resolved internally. Referring any query to the National Clinical Coding Query Mechanism including the completion of the relevant query proforma information if appropriate (see Appendix B). 7.0 Structure of the clinical coding department. Current coding structure is hierarchical based with 3.39 whole time equivalent band 4 experienced clinical coders. 05/12/2013 Page 13 of 27

CLINICAL CODING MANAGER ACC X 0.93WTE BAND 4 Mental Health X0.93WTE BAND 4 Mobile Coder X3 part Time Band 4 Covering Day case and Community Currently the structures support devolved coding function, with community coders located within community sites across the county.main workload being 80% day case work, with the rest made up from inpatient community beds.which can be stroke, fractured neck femur rehabilitation, general rehabilitation and palliative care. Two fulltime coders cover mental health unit and any outlying mental Health/ Community sites. Clinical coding sits within Finance, Performance and Information Directorate with direct reporting to Records transformation and Information Governance manager, under the Chief Information Officer. 8.0 Management and Training The Clinical Coding Manager will ensure that the Team attends all training as necessary. To endorse national standards and the rules and conventions of ICD-10, OPCS-4 and to create an awareness of the importance and eventual use of the data i.e. clinical governance, local management, and national statistics. Training Programme for Clinical Coders: Attendance to Clinical Coding Foundation Course or Mental Health Foundation Course within six months of appointment for all new coding staff Attendance on the Clinical Coding Refresher Training Course every three years for experienced clinical coding staff Attendance on regular specialist training courses wherever available Staff will attend all Trust mandatory courses relating to health and safety, fire drill, security and confidentiality The Trust supports all clinical coders in gaining Accredited Clinical Coder (ACC) status. 05/12/2013 Page 14 of 27

8.1 Induction Programmes for New Staff All new starters will attend two day corporate induction before commencement of duties. Band 3 Trainee clinical coders Any new clinical coder s with no experience will be required to complete a training schedule, this programme will: 1. Successful completion of clinical coding foundation course as delivered by connecting for health. (Within 6 months of appointment) 2. In house training programme to include 1:1 supervision, on the job training, IT system in house training 3. Passed internal assessment this will include theory paper and practical paper. 4. on successfully completing internal assessment and satisfactory personnel interview trainee coder will attain band 4 junior clinical coder status. o Band 4 experienced Coders commencing employment with trust will have their training needs assessed.support will be offered through coding manager and peer group. 8.2 Experienced Coders All existing Clinical Coding Staff within the trust are expected to keep their coding skills and knowledge uo to date and valid via compliance with the following training /knowledge & skills programme: Satisfactory completion of training schedule for newly appointed band 3 coders. 1. Attendance at any regionally designed /delivered Clinical Coding Refresher training course every 2-3 for experienced clinical coding staff. 2. Attendance at monthly clinical coding dept. team meetings, where coders will be expected to participate in discussion, presentation and review of relevant clinical coding issues, delivery of service and review of data quality. 3. Regular review of any coding clinic guidance issued and amendment of coding manuals / documentation where necessary, or amendment instructed by coding clinics. 4. This to include any special instructions detailed in of local policy document, especially when a coder is commencing coding in an area unfamiliar to him/her ie another hospital,ward, specialty. 5. Attendance on regular specialist training courses wherever available, as identified via PDR. 05/12/2013 Page 15 of 27

6. Attendance on relevant computer training courses to update IT skills. 8.3 Training of Non-Coding Staff Training programmes for users of coded information and those who produce the Information for coding purposes (e.g. awareness sessions, participation at induction programmes by new medical staff, etc.) will be made available. Local Clinical Coding Policies Any decisions made at local level with individual clinicians are to be fully documented and endorsed by the relevant consultant/group at LPT. All decisions must however conform to national standards as agreed by the NHS Connecting for Health. See Appendix D for completed Policy Training form 9.0 Security and confidentiality LPT takes the confidentiality of its patients and service user s data very seriously. To this end this Policy and procedure document sets out steps that should be taken and awareness clinical coding staff must have when carrying out their duties. Such internal measures should include details of: 1. All Clinical Coding staff dealing with patient identifiable information to have signed the Trusts security and confidentiality policy 2. All Clinical Coding within the department are aware and maintaining their awareness of the policies and procedures governing the disclosure and sharing of data both internally and with external organisations operated by the Trust. 3. All Clinical Coding staff should be aware of the departmental policy that any information being forwarded to external sources for coding queries should be completely anonymous 4. All Clinical Coding Staff within the department should be aware of who their Caldicott guardian is, should issues in security and confidentiality of patient identifiable information arise. 5. All Clinical Coding staff should be familiar with and have access to the following confidentiality and security documentation a).the Data Protection Acts (1984 and 1998) b).the Protection and Use of Patient Information (HSG(96)18) and HSG 2000/009 c).the Access to Health Records Act (1990) 6. Clinical Coders as users of Clinicom PAS must attend formal training, which is organised by the trust s PAS system manager.once issued with a PAS password it becomes the clinical coder s responsibility to ensure that such logins and passwords as issued are not shared with others, but remain under the sole use of the clinical coder. 05/12/2013 Page 16 of 27

7. All data entry systems should have an audit trail and allow the identification of users accessing the system and /or uploading clinical coding data, to include times of when such transactions occurred. 8. No data will be shared with others outside LPT unless approved by clinical coding managers who should insure that any such release of data is anonymised and non-patient identifiable. 9. Any training issues identified in audit must be addressed promptly by clinical coding manager. 10.0 Due Regard Consultation has taken place involving staff across all protected characteristics. Already established patient groups have also provided feedback in relation to the way that professional groups record and store information. There is no likely adverse impact on staff or service users from this policy as all patient information should be recorded in line with clear standards in order to support their on-going care and treatment.this policy sets out what these standards arein relation to the coding of the activity associated with their care and treatment and the steps to ensure these are met. Benefits to the organisation in regard to savings include increased staff awareness of their legal and statutory duties in relation to the recording and management of information. 11.0 Monitoring Compliance 11.1 Audit and Outcomes Audit against these standards will take place annually in line with the requirements of the Information Governance Toolkit standard 516 All coding audits will be undertaken in the format as described in the this policy and procedure document at section 6. Arrangements for reviewing the associated action plans developed from the audit will be managed in line with the criteria set out within this Policy and procedure. The availability of case notes will also be monitored and measured. Successful outcome from the use of the guidelines would be: High standards of clinical record keeping Clinical record keeping that supports communication and planning of care Quality of data capture within clinical record that supports commissioning activity and benchmarking 11.2 Process for Monitoring Compliance The implementation of this policy will be monitored by the Records and Information Governance Group. 05/12/2013 Page 17 of 27

Compliance with this policy will be measured through:- The resulting outcomes presented from the annual IGT clinical coding audit and the review of associated action plans Outcomes through the validation programme The dissemination mechanism and implementation plan will form part of the Information Governance Communications Plan with reference to all Information Governance related policies. See Appendix 3 for Policy Monitoring form 12.0 Review The Clinical Coding Manager is responsible for ensuring this document is reviewed and, if necessary, revised in the light of legislative, guidance or organisational change. Review shall be at intervals of no greater than 2-years. Any revisions to this document shall be agreed through the approval process indicated on the title page. 12.1 Archiving The Corporate Services Manager is responsible for ensuring that superseded versions of policies and procedures are retained in accordance with the Records Management: NHS Code of Practice 2006 13.0 References National/Regional Clinical Coding Query Service Proforma If you have a local proforma and mechanism it should be included here. If this is not available and your Trust uses the NHS Classifications Service proforma this can be found at: www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/data_quality/query_mech Health Service Guideline: The Protection and Use of Patient Information http://www.doh.gov.uk/nhsexipu/confiden/protect/index.htm This includes information on HSG(96)18 / LASSL(96)5 Health Service Guideline The Protection and Use of Patient Information The Protection and Use of Patient Information Guidance from the Department of Health The Data Protection Act 1998 HSC 2000/009 The Data Protection Act 1998: protection and use of patient information NB: The Data Protection Act 1998 became effective from 1 st March 2000, and superseded the Data Protection Act 1984 and the Access to Health Records 1990. 05/12/2013 Page 18 of 27

The Data Protection Act 1998 gives every living person the right to apply for access to their health records. The exception to this is the records of the deceased person that are still governed by the Access to Health Records 1990. Other useful links: Patient Confidentiality and Caldicott Guardians: Frequently Asked Questions http://www.doh.gov.uk/nhsexipu/confiden/faq.htm 05/12/2013 Page 19 of 27

Appendix A Key Guidance Documents: The Clinical Coding toolbox available on line at: http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codin gadvice/toolbox/coder/?searchterm=clinical%20coding%20toolbox The Coding Clinic Publication Connecting for Health available online at: http://www.connectingforhealth.nhs.uk/search?searchabletext=coding+clinic Other useful links: Primary diagnosis definition Health Service Guideline HSG (96) 23, 20 th September 1996; mandated and implemented across the NHS from 1 st April 1997. SNOMED Clinical Terms: http://www.connectingforhealth.nhs.uk/systemsandservices/data/uktc/snomed Dictionary of Medicines and Devices: available online at: www.dmd.nhs.uk/ The World Health Organisation ICD10 available online at: www.who.int/classifications/icf/en/ The Information Centre What are Healthcare Resource Groups (HRGs)? Available online at: http://www.ic.nhs.uk/services/the-casemix-service/new-to-this-service/what-are-healthcareresource-groups-hrgs DOH - PbR Code of Conduct available online at: Code of Conduct for Payment by Results (Gateway No: 6058), Patient Confidentiality and Access to Health Records available online at: http://www.dh.gov.uk/en/managingyourorganisation/informationpolicy/patientconfide ntialityandcaldicottguardians/index.htm Data Protection Act 1998 available online at: 05/12/2013 Page 20 of 27

http://www.dh.gov.uk/en/managingyourorganisation/informationpolicy/recordsmana gement/dh_4000489 Confidentiality NHS Code of Practice (2003) DH available on line at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_4069254.pdf Information Security Management NHS Code of Conduct (2007) DH available on line at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/document s/digitalasset/dh_074141.pdf 05/12/2013 Page 21 of 27

Appendix B National/Regional Clinical Coding Query Service Proforma NHS ICD-10/OPCS-4 proforma this can be found at: http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codin gadvice/national/index_html/?searchterm=clinical%20coding%20query Email Completed form to: Datastandards@cfh.nhs.uk or fax 01392 206945 All queries are logged onto the Help Desk database to facilitate analysis and effective refinement of training product initiatives. In order to ensure that all Clinical Coding Queries are answered accurately and in accordance with National Standards, the level of information requested on the clinical coding proforma is necessary in order to formulate a resolution. Please ensure that all parts of the proforma are completed and contain as much information regarding the intervention or clinical finding as possible. All queries to the Data Standards & Products Helpdesk must be submitted on the correct proforma The Help Desk, whether a query is submitted on a proforma or contacted direct, requires the same information, including the specialty under which the patient is/was treated, and any supporting documentation facilitate a 3 5 day turnaround. Providing a quick response is dependent on queries being sent directly to the Help Desk as they are raised, rather than sending in 3 or 4 at a time. These coding queries are resolved by Clinical Coding Officers. If unresolved however, the query is then submitted to the UK Coding Review Panel for consideration, who may well require further details from the clinician or clinical coder. This type of query usually relates to rare or unusual occurrences and/or to classification/coding issues, which require national policy to be clarified, modified or developed. Queries referred in this way take longer to resolve, due to necessary consultation. Resolutions of this Panel are published in the Coding Clinic insert (where applicable), which provides a supplement to the Clinical Coding Instruction Manual ICD- 10/OPCS-4, as it may incorporate changes to national clinical coding standards. For this reason it is important that coders, who hold a copy of the Instruction Manual, also receive a copy of the Coding Clinic collection, which is contained in a binder incorporating Coding Clinic inserts for easy reference. Updates are sent to the recipients of the binder when the latest issue of the Data Quality Review is published. It is therefore, only necessary for a department to hold one copy of the Data Quality Review newsletter. 05/12/2013 Page 22 of 27

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Appendix C Policy Monitoring Section NHSLA Criteria Number & Name (if applicable): Where applicable NHSLA duties outlined in the policy will be evidenced through monitoring of the other minimum requirements. Where monitoring identifies any shortfall in compliance the group responsible for the Policy (as identified on the policy cover) shall be responsible for developing and monitoring Reference Minimum Requirements to be monitored IGT 508 To have a Clinical Coding Policy and procedure in place based on Health & Social Care Information Centre template IGT 516 External audits are undertaken once a year on a sample of at least 200 clinical records Evidence for selfassessment Monitoring Process for IGT Evidence IGT 360 Assurance Audit Report External Auditors report Audit Report Responsible Individual / Group Records and Information Governance Group Records and Information Governance Group Frequency of monitoring Annually Annually 05/12/2013 Page 24 of 27

Appendix D Policy Training Requirements The purpose of this template is to provide assurance that any training implications have been considered Training topic: Type of training: Division(s) to which the training is applicable: Clinical Coding Mandatory (must be on mandatory training register) Role specific Personal development Adult Learning Disability Services Adult Mental Health Services Community Health Services Enabling Services Families Young People Children Hosted Services Staff groups who require the training: Clinical Coders Consultants Junior Medical staff Update requirement: Who is responsible for delivery of this training? Have resources been identified? Has a training plan been agreed? Where will completion of this training be recorded? Every 3 years Clinical Coding Manager As required Included as part of the procedure Trust learning management system Other (please specify): Personal File How is this training going to be monitored? Through Clinical Coding Validation work November 2013 05/12/2013 Page 25 of 27

Appendix E Due Regard Screening Template Section 1 Name of activity/proposal Development of Clinical Coding Policy & Procedure Directorate / Service carrying out the Clinical Coding assessment Name and role of person undertaking Sam Kirkland, Records Transformation & this Due Regard (Equality Analysis) Information Governance Manager Give an overview of the aims, objectives and purpose of the proposal The purpose of the document is to promote good practice and consistency of information being produced through clinical coding processes within Leicestershire Partnership NHS Trust (LPT). It has also been designed to ensure information produced during the coding process is accurate and adheres to local and national policies. Section 2 Protected Characteristic Age Disability Gender reassignment Marriage & Civil Partnership Pregnancy & Maternity Race Could the proposal have a positive impact (Yes or No give details) Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to Could the proposal have a negative impact (yes or No give details) No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is 05/12/2013 Page 26 of 27

Religion and Belief Sex Sexual Orientation date Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to date Yes Ensures that clinical data is accurate and up to date accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users No The Policy is to ensure that data entry is accurate and up to date and it is what is expected for all service users Section 3 Does this activity propose major changes in terms of scale or significance for LPT? No Is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? If yes to any of the above questions please tick box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B No Low risk: Go to Section 4. Section 4 It this proposal is low risk please give evidence or justification for how you reached this decision: The purpose of this document is to promote good practice and consistency of information being produced through clinical coding processes within LPT. It has also been designed to ensure information produced during the coding process is accurate and adheres to local and national policies. It will ensure that the systems and processes for capturing and monitoring coding activity is fit for purpose and supports the patients journey. There is no likely adverse impact on staff or service users from this policy as all patient information should be recorded in line with clear standards in order to support their ongoing care and treatment.this policy sets out what these standards are in relation to the coding of the activity associated with their care and treatment and the steps to ensure these are met. Sign off that this proposal is low risk and does not require a full Equality Analysis: Head of Service Signed: Sam Kirkland Date: 18/11/2013 05/12/2013 Page 27 of 27