Do we need endless clinical codes when we get sick?
Posted on 3 April 2018
Each time you are informed that a hospital admission is on the cards, you are provided with endless clinical codes relating to your admission. But what do they actually mean?
Clinical coding is an essential part of the information flow within the healthcare industry. While confidentiality of patient information is a key legislative requirement for which clinical codes are used, the codes also assist in data storage and payment facilitation.
Clinical coding is the translation of clinical information into codes. Clinical coding is an international language used among healthcare providers across the world.
What do the clinical codes actually mean?
There are three key coding structures used during a patient event. The first are diagnosis codes known as ICD 10 codes – for example acute tonsillitis would be referred to as J03.9 if it is a basic infection but may vary to J03.8 or J03.0 depending on the specific causative organism of the infection.
The second code structure is CPT / CCSA known as procedure codes that the hospital will provide to the patient’s Medical Aid scheme when obtaining authorization for a procedure. These CPT /CCSA codes tell the medical aid what surgery the doctor is planning to do or did. There are specific clinical levels for procedures. A doctor may indicate planning on performing a tonsillectomy plus an adenoidectomy or just a Tonsillectomy which will alter code selection. CPT /CCSA codes provide the scope of the surgery the medical aid will have to authorise.
The third coding structure is Tariff Codes, used by all Healthcare provider groups and is industry approved billing coding structures. These coding structures are used for reimbursement purposes to assist with consistency in claiming and to standardise Rand value per service. This will be the professional fee a doctor levies for administering whatever treatment he performs. The doctor will provide to the patient with tariff codes to obtaining authorization for an admission or a procedure.
Why do healthcare providers use clinical codes?
The healthcare industry uses clinical codes to obtain a common understanding of clinical diagnostic and procedural information. By simplifying the information, clinical codes facilitate the storage, retrieval and statistical analysis of clinical information for comparison and decision-making. It enables consistency in capturing clinical information of patients. Clinical coding also facilitates consistency in reporting to South African legislative bodies. Alternative Reimbursement Models (ARMs) are built on clinical coding.
What are the benefits of clinical coding to you as the patient?
Simply put, once your medical aid has received the tariffs and approved them, you know whether the procedures will be fully covered or what your financial obligations will be. The information in your file is coded so that patient confidentiality is maintained should the casual onlooker be exposed to any elements thereof. A clinical code could indicate the severity of a disease e.g. renal failure, which can trigger additional benefits such as the prescribed minimum benefits a medical aid legally obliged to provide to a patient.
Coding also assists healthcare providers to act within legislatively prescribed reporting guidelines where personal patient details should be removed, for example hospitals are obliged to report incidents of communicable diseases such as TB or meningococcal infection. These clinical codes prescribe what is required to be reported and the respective health department can track potential outbreaks and react swiftly to any potential spread of infection without the risk of confidential patient information being released.
Tracking health care trends within a country is also facilitated by these clinical codes for example, a motor vehicle accident can be coded down to whether the patient was a passenger, driver or pedestrian – type of vehicle for e.g. whether it was a motor vehicle, motorbike or bus collision, etc. These stats are reported and used by the authorities when understanding particular trends without specific patient details being revealed to the particular authority.
Clinical codes can even speak to the patients need to retain certain information from a medical aid. Should a patient present as HIV positive and that individual chooses not to reveal this to the funder, a clinical code can be used indicating to the medical aid scheme the patient opted not to have the Hospital share certain clinical information. While this may transfer some financial risk onto the patient this also assures them of the right to decide whether information is provided to specific third parties.
The World Health Organization (WHO) is also able to track international tendencies through coding of information such as the causes of infant mortality or the spread of HIV/ AIDS. Providing global trends on diseases that feature across many or some of the countries reporting into WHO.
Let the code speak for you
So next time you are confronted with a string of numbers or codes issued by your medical practitioner as you prepare for an admission to hospital or operation, take comfort in the fact that these numbers/codes make the healthcare world go round while also keeping your personal information private during the reporting process.