From coding to clinical nurse specialist: how a review of coding practice enabled hysteroscopy nurse development

Within the NHS, there is a growing disconnect between training health professionals and changing patient demands on the healthcare system. Therefore, as these demands increase and a shortage of medical doctors intensifies, a reshaping of the NHS is required (Wiseman, 2007; Woo et al, 2017). To this end, expanding the skills of registered health professionals and supporting the development of clinical nurse specialists are critical goals if the NHS is to meet the changing healthcare demands of the UK population (Imison, 2016). These objectives are outlined in the NHS Long Term Plan (NHS England/NHS Improvement, 2019). In this document, it is suggested that facilitating nurses to deliver advanced levels of practice is effective in meeting the ever-changing nature of patient needs while improving job satisfaction and workforce sustainability (NHS England/NHS Improvement, 2019).

The expansion of the nursing role has already made rapid progress over recent years. Nurse-led clinics are now a well-established care delivery system and many tasks previously reserved for doctors are considered to be within the remit of nurses. Nevertheless, if the NHS workforce is to adapt to oncoming challenges, a concerted effort to facilitate sustainable nurse development is required. Outpatient gynaecology clinics are an example where nurse development has already impacted care delivery. Nurse practitioners currently autonomously perform the majority of colposcopies (an endoscopic diagnostic procedure of the cervix and surrounding structures), which is a technique historically performed only by doctors (Jones, 2005). Enabling nurses to perform this procedure has proven successful in managing the large number of patients requiring colposcopy as a part of the NHS cervical screening programme (King and Busolo, 2022).

The outpatient gynaecology department also performs diagnostic and therapeutic hysteroscopy (a procedure that involves gaining access through the cervix to visualise the uterine cavity) (Royal College of Obstetricians and Gynaecologist/British Society for Gynaecological Endoscopy (RCOG/BSGE), 2011). It is a commonly performed, safe and cost-effective way of diagnosing and treating patients with abnormal uterine bleeding or other benign and premalignant gynaecological conditions (RCOG/BSGE, 2011). Currently, hysteroscopy procedures are almost exclusively performed by doctors.

However, this may be set to change in the coming years. Bradford University offers the only academically credited hysteroscopy training course for nurses in the UK (held to the standards of the BSGE). The hysteroscopy programme aims to develop nurses to lead a ‘see and treat service’, delivering an advanced level of practice and working across professional boundaries. However, supporting the training of nurses to this level of practice involves high staff costs, so adequate funding must be available within the department.

Capturing lost income by improving clinical coding can provide surplus funds for staff development. Clinical coding is the method by which departments are reimbursed for the services they provide to patients, and is central to the Payments by Results (PbR) system introduced within the NHS in 2002. However, although this system has been in place for over 15 years, the accuracy of clinical coding within the NHS is generally poor: one study showed that for a group of 208 emergency general surgery patients, 93.3% had at least one error in clinical coding (Heywood et al, 2016). Additionally, the importance of clinical coding extends beyond the distribution of funding. Achieving a high level of accuracy is also required for more targeted allocation of healthcare resources, analysis of trust performance and generation of public health data (Campo et al, 2018).

Therefore, the authors audited the clinical coding in their outpatient hysteroscopy department and considered how improving the accuracy of this process could facilitate nurse development.

Aims

• To audit the clinical coding of outpatient hysteroscopy clinic appointments in the authors' institution
• Discuss why clinical coding is inaccurately performed
• Evaluate how to implement changes to coding protocols to improve accuracy
• Discuss the implications of this audit for other institutions and how improved clinical coding accuracy can enable clinical restructuring, facilitate nurse development and improve the delivery of care.

Patients and methods

Clinical coding of hysteroscopy procedures

In the outpatient department St Michael's Hospital, Bristol, the clinical coding procedure begins with the responsible clinician completing a paper outcome form after each consultation, which should outline which service was provided to the patient. Next, a member of the administration team transposes this information to the online patient administration system (PAS) via a data entry checklist (Figure 1). Healthcare resource group (HRG) codes are generated automatically based on the data entered on the PAS checklist. Each HRG code has a monetary value that is used to reimburse departments for the work they perform. In theory, each HRG code should represent the healthcare resources used in each appointment.

Hysteroscopy appointments can attract tariffs of up to £825. Therefore, inaccurate clinical coding can result in a significant difference in income to the gynaecology department. Historically, this procedure would have been performed under general anaesthetic in theatres. However, due to recent advances in endoscopic technology, uterine cavities can be visualised safely and with less discomfort, meaning that the majority of hysteroscopies are now performed in the outpatient department (Campo et al, 2018). For hysteroscopies performed in theatre, clinicians enter the HRG code directly into the clinical coding system, bypassing the use of outcome forms, the administration team or a data entry checklist. Clinical coding for theatre hysteroscopy cases in the authors' institution has previously been audited and was found to be highly accurate.

Mahbubani et el (2018) highlighted the importance of documentation and up-to-date coding systems to ensure the payment by results system functions well. Therefore, given the recent shift from theatre to outpatient hysteroscopies and the potential for documentation errors in our outpatient coding process, the authors audited the clinical coding practice in their outpatient hysteroscopy appointments to determine the accuracy of tariff re-payments.

Methods

This project was undertaken as a locally registered quality improvement project, and further ethical approval was not required.

The authors analysed the clinical coding of outpatient hysteroscopy clinic appointments before and after introducing interventions hoping to improve accuracy. To assess coding accuracy, they analysed the clinic notes of hysteroscopy appointments given a ‘non-hysteroscopy HRG code’. Appointments with a ‘non-hysteroscopy HRG code’ are defined as any outpatient hysteroscopy clinic appointment where the HRG code, which was issued for repayment, did not indicate that a diagnostic or therapeutic hysteroscopy was performed. By analysing these appointments, the authors were able to identify all instances where a hysteroscopy was performed, but coded inaccurately.

Coding discrepancies were identified by comparing the clinical information written on clinic letters with the HRG code used to reimburse the hospital. Only the first four appointments on the clinic list were eligible for analysis because hysteroscopy procedures are performed at the beginning of clinic lists at St Michael's Hospital. In contrast, later appointments are utilised for reviewing results.

form was filled in accurately, the error is due to a mistake in transposing this information to the PAS or a blind spot in the coding protocol.

Analysis was performed using Microsoft Excel functions and tabulations. Comparative financial analysis was completed to ascertain the impact of the action plan on total yearly tariffs received by the department. ‘Miscoded hysteroscopy tariffs’ were appointments where a hysteroscopy successfully took place but was coded for incorrectly, attracting only a ‘no procedure’ tariff of £68. When a miscoded hysteroscopy appointment was identified, the appropriate value of the appointment (according to the National Tariffs Workbook 2019/2020) was subtracted from the value that had been reimbursed to the department (Table 1). Missed income from inaccurate coding of failed hysteroscopies and polypectomies/MyoSure tissue removal (hysteroscopic procedures whereby polyps or fibroids are removed from the uterus) was calculated using the same method. The sum of all missed tariffs was calculated for the control and intervention periods. The control and intervention period represented a 3-month sample, so these figures were extrapolated to give yearly estimates.

The impact of the action plan was appraised via analysis of any improvement in the rate of correctly coded appointments in the intervention versus control sample. In addition, coding accuracy improvement could be quantified from a reduction in missed tariffs due to miscoded hysteroscopies, and gained tariffs from correctly coded failed hysteroscopies and polypectomies/MyoSure tissue removal procedures.

Results

During the control period, 59% of non-hysteroscopy appointments were given an HRG code that was not representative of the healthcare resources used during the consultation (Figure 2). Despite being coded as non-hysteroscopy appointments, a hysteroscopy was performed successfully in one third of the control period sample. Transposition errors were the most common reason for these miscoded appointments (69%) (Figure 3). Transposition errors are defined as instances where the outcome form was accurate, but the HRG code did not represent the resources used in the appointment. Mistakes in outcome form documentation were responsible for 31% of errors.

In addition, appointments during which a clinician attempted a hysteroscopy but failed to complete the procedure only attracted a base-rate tariff of £68, despite the healthcare resources spent. Moreover, the authors noticed that appointments in which a resection procedure was performed (polypectomy or MyoSure tissue removal) were coded as a standard hysteroscopy procedure (£341), meaning that they did not attract the correct tariff of £825 (Table 1). A hysteroscopy plus polypectomy or MyoSure tissue removal is a diagnostic and therapeutic procedure where the clinician performs a hysteroscopy and removes an interuterine polyp.

As transposition errors were responsible for more than two-thirds of miscoded hysteroscopies, the authors' action plan was targeted at improving this. The authors investigated why these errors were so prevalent and found that the outcome form checklist that clinicians completed following clinic appointments did not directly match the PAS data entry checklist used by administration staff.

This meant that administration staff, who are not clinically trained, were making best-guess decisions about which boxes to tick on the PAS checklist. Consequently, the authors created a new outcome form that directly matched the PAS data entry checklist. In addition, the authors worked with coders to change the pathway by which failed hysteroscopies and polypectomies were coded, to ensure that they would attract a fair tariff relative to the healthcare resources used during these appointments. This action plan was initiated on 1 April 2020.

The action plan was highly effective. The frequency of miscoded appointments fell from 59% to 15% (Figure 2). On further analysis, the authors found that the improved accuracy was the result of a reduction in the frequency of information transfer errors to the PAS (Figure 3); failed hysteroscopies were now coded for correctly and resection procedures now attracted an appropriate tariff. However, inaccurate outcome form documentation by clinicians persisted despite the authors' interventions.

Financial analysis

As a result of improved clinical coding accuracy, the department saw a £28 816 rise in yearly tariffs when comparing the control and intervention periods (Table 2). The reduction in miscoded hysteroscopy appointments was responsible for £7740 of the surplus income. Appropriate coding of failed hysteroscopies and resection procedures contributed £5324 and £15 752, respectively.

Discussion

The audit described in this article demonstrates how simple changes in coding procedure can lead to dramatic improvements in accuracy. The authors' action plan successfully reduced transposition errors and addressed blind spots in our clinical coding procedure relating to how resection procedures and failed hysteroscopies were reimbursed. As a result of improved clinical coding accuracy, sustainable increases in income to the department were attained without incurring any additional administrative costs.

The underlying problem identified in the department's clinical coding procedure was that the administrative system did not keep pace with clinical changes, ie the move from theatre to outpatient hysteroscopies. This is supported by data from previous audits in the department, which found that clinical coding for theatre hysteroscopy cases was highly accurate. Therefore, by updating the administrative systems and reducing subjectivity in the coding process, substantial improvements to clinical coding accuracy can be attained with meaningful consequences to patient care and departmental efficiency. The authors discovered significant errors in clinical coding accuracy, despite previous audits on this topic within the department in recent years. Therefore, given that clinical coding is generally inaccurately performed within the NHS, the errors outlined in this article are likely to be occurring in other departments across the UK. Therefore, careful auditing of clinical coding procedures should be a priority, especially in areas where the coding procedure may not be up to date with clinical restructuring.

The surplus income gained from improving the accuracy of clinical coding in St Michael's Hospital outpatient gynaecology department was used to facilitate the training of a new nurse hysteroscopist (via the Bradford University hysteroscopy course) and support ongoing staff costs. However, the surplus income can only be reinvested in the department, given a cost-effective proposal that the outlay will improve the standard of care delivered by the wider trust. Therefore, the cost of any restructuring must be clearly defined so that managers can make an informed decision about the viability of any initiative.

Supporting the training of a new nurse hysteroscopist comes with both upfront and ongoing costs to the department. As an example, tuition fees to enrol on the course at Bradford were £3684 for 2020/2021. In addition, during the training period, the local gynaecological department will be put under an 18-month-long cost pressure period because extra staff costs are necessarily incurred to cover existing clinical duties which cannot be performed during the training period. Each trainee also requires local consultant-level supervision, adding to the workload strain put on the department. Moreover, once trained, the nurse hysteroscopist will attract a salary at band 8 level, require secretarial support and a designated facility for their hysteroscopy clinic, including IT facilities (such as personal computer, printer and secure filing). These represent an extra ongoing staff cost for which adequate funding must be available.

Other costs that may need to be subsidised include membership to the BSGE, additional training modules and designated support from clinical supervisors. It should also be noted that the BSGE offer a 50% bursary for the training of nurse hysteroscopists, and each hospital also has funding dedicated to continued professional development for nurses. The audit and changes in practice described in this article led to improvements in clinical coding, resulting in a £28 816 rise in yearly tariffs, which meant that the ongoing cost of a new nurse hysteroscopist could be covered comfortably.

The benefits of enrolment in the training programme must be compelling to both managers and patients. The specific methods by which the training of nurse hysteroscopists can improve the provision of care and workforce sustainability include:

• An increased departmental capacity for hysteroscopy appointments. In the authors' institution, this has helped to ensure that the 2-week wait targets for suspected gynaecological cancers are met and has helped tackle the nationally recognised waiting list following the COVID-19 pandemic
• Increased flexibility of access to care. Nurse hysteroscopist clinics at St Michael's can run out of standard working hours, meaning that patients previously unable to attend hysteroscopy appointments can be cared for appropriately and offered a wider variety of appointment times. Wygant et al (2020) utilised nurse hysteroscopists as a part of their gynaecological department and found that this reduced waiting times and improved efficiency and access to appointments
• Improved patient satisfaction. According to patient surveys and data from the NHS England's Friends and Family feedback test (https://www.england.nhs.uk/fft), patients were found to be highly receptive to consultations with advanced clinical practitioners (ACPs), stating that they felt listened to and preferred the continuity of care that ACPs can provide (Pearce and Breen, 2018).

Consequently, empowering nurses to perform advanced practice can improve departmental efficiency (benefiting managers) and provide improved, holistic care for patients. Improving clinical coding accuracy can be used as a vehicle to facilitate such change.

As discussed, the benefits of more accurate clinical coding extend beyond financial gains. Improved clinical coding accuracy means that clinical commissioning groups (CCGs) will be given more accurate data on how healthcare resources are used in trusts. Therefore, CCGs will be able to make informed decisions on how to best meet patient needs and budget for improvements in departmental efficiency and staff development. In the authors' institution, this led directly to nurse development, a critical factor in improving the NHS's efficiency, sustainability and care standards.

Limitations

The chief limitation of this report is that the authors only present a single-centre experience. The nature and incidence of clinical coding errors in other institutions will vary. It should also be noted that, despite the authors' interventions, coding errors persisted in the intervention group compared with the control period, albeit considerably reduced (15% versus 59%). These coding errors represented £11 400 of uncaptured income to the department. Two-thirds of coding errors that persisted were due to inaccurate documentation, highlighting the importance of precise documentation in the functioning of the NHS's PbR system.

It is to be hoped that as St Michael's moves from paper-based to electronic note-taking systems, documentation errors will improve. An electronic note-taking system may also reduce transposition errors related to illegible handwriting. Nevertheless, as a hospital that has previously been aware of coding discrepancies with several previous audits undertaken in this area, the authors are confident that lessons can be learnt from their experience across the NHS, leading to meaningful change.

Conclusion

The provision of health care for the future will continue to be challenging. Workforce flexibility and efficient allocation of resources are vital objectives if the NHS is to meet increasing expectations and expanding demands.

Clinical coding is an essential requirement and central reality of funding in the modern NHS. However, it is inaccurately performed in many instances despite best efforts. Nevertheless, as the audit described in this article demonstrates, simple changes in coding procedure can vastly improve coding accuracy. At St Michael's Hospital this directly led to clinical restructuring and meaningful improvements in the provision of care. Future initiatives should be directed at improving clinical coding–it is a tool that is crucial to the function and improvement of the NHS and is often overlooked by those hoping to implement change.

KEY POINTS

• Clinical coding is an essential requirement of funding the modern NHS. However, it is inaccurately performed widely within the NHS despite best efforts
• Simple changes to coding procedures can make a significant difference in improving clinical coding standards
• Improved clinical coding can facilitate meaningful improvement in care provision by helping to facilitate clinical restructuring and enable nurse development

CPD reflective questions

• Identify how clinical coding is performed in your specialty and consider whether this process should be audited and optimised
• Reflect on your career aspirations and what funding your department requires to help you achieve this
• Reflect on the use of advanced nurse practitioners in your organisation and their role in care delivery
• Consider whether the improvements in clinical coding described in this article have implications beyond hysteroscopy clinics and the outpatient department
• Could the audit described in this article be replicated in your department?