SP5.04 Accuracy of Clinical Coding in General Surgery and its financial impact

Aim To assess the accuracy of clinical coding for patients admitted in the department of General Surgery, to compare with national standards and to measure its financial impact. Methods 50 patients admitted under General Surgery between June and August 2023 were selected for the first cycle, followed by another 50 patients for second cycle between June and August 2024. Clinical notes and discharge summaries were analysed by members of the surgical team from patient notes, data on Bamboo and data provided by coding department. Incomplete information on discharge summaries, errors in diagnosis and procedures that triggered a change in clinical code were noted. Final audit of the listed patients and its financial impact was performed by coding department Results Primary diagnosis was correctly coded in 90% cases in first cycle increasing to 93.83% in second cycle. Secondary diagnosis was correctly coded in 80.63 % cases in the first cycle, increasing to 91.01% in second cycle. Primary procedure was correctly coded in 86.49% cases in first cycle, increasing to 90.24% in second cycle. Secondary procedure was correctly coded in 91.35% cases in first cycle and 90.66% in second cycle. The general standard of coding was good with all metrics exceeding the standards as per national clinical coding guidelines. Financial impact of the first cycle was 38,760£. Financial impact of the second cycle was 17,836£. Conclusion Coding errors are responsible for significant financial loss to the trust which will affect adequate provision of health services and resources distribution.