'Sailing the seven Cs' with the Clinical Coders' Creed. The eighth 'C': private sector Coding.
Abstract: This article briefly relates the experience of a clinical coder working in the private healthcare sector in the Australian state of New South Wales and questions whether it is possible to work in this environment while adhering to the Clinical Coders' Creed. Private facilities in Australia that handle acute, psychiatric, respite and rehabilitation cases, rely mainly upon health insurance funds for reimbursement for episodes of care, which are funded according to DRGs based on codes assigned by clinical coders. The point is made that while all coders strive to fully and accurately describe the clinical episode of care regardless of healthcare setting, a distinction can be drawn between public and private sector coding in relation to financial contracts, which form the basis of private health care. Therefore, it is recommended that private sector coders familiarise themselves with this "C" as well as the other seven "Cs" of the Clinical Coders' Creed.

Keywords (MeSH): ICD-10-AM; Clinical Coding; Australia; Private Sector.
Article Type: Report
Subject: Documentation (Management)
Medical protocols (Evaluation)
Practice guidelines (Medicine) (Evaluation)
Author: Prudames, Fiona
Pub Date: 02/01/2009
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Feb, 2009 Source Volume: 38 Source Issue: 1
Topic: Event Code: 360 Services information; 350 Product standards, safety, & recalls; 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8060010 Private Hospitals NAICS Code: 622 Hospitals SIC Code: 8062 General medical & surgical hospitals; 8063 Psychiatric hospitals; 8069 Specialty hospitals exc. psychiatric
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 216488656
Full Text: When I commenced coding in the private sector after 15 years of public hospital coding I thought of myself as an experienced clinical coder, skilled in the Seven Cs. The private healthcare sector, however, has another dimension: Contracts. There are contracts between private healthcare facilities and health funds, between health funds and their members, and between private healthcare facilities and government departments. The clinical coding of an episode can have an impact on any of these contracts.

Currently I am employed as a clinical coder at Forster Private Hospital, a 70-bed acute-care private hospital that is operated under commercial lease by Pulse Health Limited. This hospital is engaged in an exciting and challenging project to contract public hospital patient care on an ongoing basis. It is the first contract of its kind in New South Wales, being a long-term agreement between the Hunter New England Area Health Service and Pulse Health Ltd. Not surprisingly, contracts are involved in these negotiations.

While clinical coding is not the sole axis for private hospital invoicing, private sector coders need to be aware of the basic tenets of the contracts in order to ensure that the coding accurately reflects the episode of care to be billed. My observation is that just as coders need to clarify documentation for clinical purposes, they also need to clarify documentation for contract purposes. Private hospitals rely mainly on health insurance funds for reimbursement of episodes of care. A contract between the two parties specifies the applicable care types, whether episodes are paid per diem or by Diagnosis Related Group (DRG), and the chargeable rates for bed days, services and prosthetics. A patient may have 'out-of-pocket' expenses for their episode of care depending on the private hospital fees and the details of their fund membership contract.

At first I thought there would be a conflict between the Clinical Coders' Creed and the need to ensure that episodes were coded within the requirements of contracts. Instead I have found I have an increased reliance on the creed, particularly Clinical documentation, Communication and Coding standards, as I endeavour to record accurately the clinical and contractual aspects of care. I have, however, encountered some recurring themes, and wonder if other coders have had similar experiences.

Coding respite care in acute care facilities

Some contracts include reimbursement for respite care. Usually the documentation in these cases is clear, and the coder can use the appropriate respite codes accordingly, but if the patient's health insurance fund does not cover respite care, and the clinical documentation is not clear, then the coder needs to seek further clarification from the clinician. This helps to ensure that the fund is billed accurately for the episode. Patients who have entered into a fund contract that does not cover this type of care are responsible for the shortfall. Informed financial consent (another contract of sorts) ensures that patients are adequately informed prior to incurring these costs.

Psychiatric cases: the 'F' code

One problem I have not quite reconciled is the use of 'F' codes to highlight psychiatric cases. I have known of health funds that do not accept medical cases with an 'F' code as the principle diagnosis. Some invoices to funds have been rejected because the patient's health cover excludes psychiatric care. I believe this is a misinterpretation of ICD-10-AM, as this chapter groups disorders based on 'cerebral dysfunction' that may be 'primary, as in diseases, injuries, and insults that affect the brain directly and selectively; or secondary, as in systemic diseases and disorders that attack the brain only as one of the multiple organs or systems of the body that are involved' [See ICD-10-AM tabular list, p. 105 (NCCH 2008)]. There are surely better indicators of psychiatric care, namely admissions under the Mental Health Act, and admissions under a qualified psychiatrist.

'It's the same, but different!'

Procedural coding is most interesting as the Australian Classification of Health Interventions (ACHI) is based on the Medicare Benefits Schedule of Fees--Australia (MBS). In private hospitals, surgeons are required to provide the MBS item numbers for the procedures they perform. These are usually written in the operative record, and used for billing funds. The coder's dilemma springs from the following factors:

* The 'item number' probably describes the procedure in ACHI terms. However, this is clinical coding and one must follow the conventions in order to establish the best possible ACHI code. It is most reassuring when the clinical coder derives a similar code!

* MBS does not equal ACHI. This can be tantalising if the item number is for a procedure of higher complexity than is reflected in the documentation, as it could mean more reimbursement for the hospital.

* The operative documentation might not support the item number assigned. Surgeons retain so much in their head that does not reach paper (operation reports)! So while the item number is correct for them, a coder cannot utilise it unless confirmed with the surgeon.

These factors can result in selection of a correct procedure code that is different from the item number.

As a clinical coder in the private healthcare sector, I look forward to becoming acquainted with the contractual and clinical data required to reflect, fully and accurately, the episodes of care contracted from the public sector.

Clinical coders are familiar with the Clinical Coders Creed, which lists seven fundamental aspects of the art and science of clinical coding: Clinical documentation, Communication with clinicians, Coding standards, Conventions, Classification experience, Common sense and sCience of medicine. They will also be familiar with the concept of 'Sailing the Seven Cs' (NCCH 1998, p.12).


National Centre for Classification in Health (1998). From the desk of the Director. Coding Matters (5)1: July.

National Centre for Classification in Health (2008). The International Statistical Classification of Diseases and Related Health Problems, Australian Modification, Sixth Edition. Available at: http://nis-web.fhs.usyd.edu.au/ ncch_new/2.aspx (accessed 9 December 2008).

Fiona Prudames BAppSc(MRA)

Health Information Manager

Forster Private Hospital

29 South Street

PO Box 159

Forster NSW 2428


Tel: +61 2 6555 1534

Fax: +61 2 6555 8750

email: medicalrecords@capehawkehospital.com.au
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.