You asked:

1. Please supply structure of your Clinical Coding Dept
2. How many FCE’s per year do you have?
3. How many Coders do you employ broken down into Bandings ( If not detailed in 1 above)
4. Do you code totally from the full Medical Record or an EPR?
5. How many separate systems are used to contribute to the Coding process by system e.g. Radiology systems, Laboratory systems?
6. Who by and how are mortality reviews undertaken within your Trust?
7. Do you have a qualified Clinical Coding Trainer or Clinical Coding Auditor?
8. Do you have an encoder?
9. Is the Clinical Coding Dept a centralised function?
10. Do the Coders visit wards to gather the coding information?
11. Are your Coders speciality specific
12. Do you have Coding runner/porters that support note delivery to the Coding Team
13. Please supply a copy of your last PbR Coding Audi

We responded:

1. Attached document ’18 – Clinical Coding Structure’
2. Approx. 262,000
3. Band 8a: 1WTE, Band 6: 4WTE, Band 5: 4WTE, Band 4: 9.16WTE, Band 3: 17WTE
4. We use the Full Paper Medical Record and have aspects of EPR
5. We have approximately 10 different systems plus our own internal validation tools
6. Mortality reviews are undertaken by each directorate and are overseen by the Trust Mortality and Morbidity Group (M&M). From a clinical coding point of view, mortality reviews are undertaken following the Clinical Coding Audit Methodology v8 by the coding senior team and reported to the M&M Group.
7. We have two qualified trainer/auditors plus one qualified auditor only and one qualified trainer only, there is also one auditor vacancy.
8. Yes – 3M Medicode
9. The clinical coding team is split over three sites, all sites perform ward based extraction from case notes and coding is applied in the coding office.
10. Yes
11. The coders rotate their specialties/wards every 6 months
12. We share with the data quality department a band 2 assistant who only picks up notes for audit work.
13. Attached PDF document ‘C05 – PbR….’

1. Attached document ’18. – Clinical Coding Structure
2. Approx. 262,000
3. Band 8a: 1WTE, Band 6: 4WTE, Band 5: 4WTE, Band 4: 9.16WTE, Band 3: 17WTE
4. We use the Full Paper Medical Record and have aspects of EPR
5. We have approximately 10 different systems plus our own internal validation tools
6. Mortality reviews are undertaken by each directorate and are overseen by the Trust Mortality and Morbidity Group (M&M). From a clinical coding point of view, mortality reviews are undertaken following the Clinical Coding Audit Methodology v8 by the coding senior team and reported to the M&M Group.
7. We have two qualified trainer/auditors plus one qualified auditor only and one qualified trainer only, there is also one auditor vacancy.
8. Yes – 3M Medicode
9. The clinical coding team is split over three sites, all sites perform ward based extraction from case notes and coding is applied in the coding office.
10. Yes
11. The coders rotate their specialties/wards every 6 months
12. We share with the data quality department a band 2 assistant who only picks up notes for audit work.
13. Attached PDF documentC05 – PbR DAF 201213 – Cluster Audit Report – Birmingham and Solihull cluster – HEFT – Final