Clinical documentation in medical records can be broadly defined as any notation made by medical practitioners and other health professionals relating to a patient’s symptoms, past history, test results or treatments provided during a clinical encounter.Clinical documentation is critically linked to accurate clinical coding and accurate generation of the diagnosis related group (DRG) resulting in appropriate remuneration to the hospital in a case-mix based funding model (Cheng et al. 2009). With the exception of DRGs ending in ‘A’ or ‘Z’, a proportionately higher level of funding may be generated for complications and comorbidities that have been treated, investigated or have required increased clinical care but have not been coded within an admitted patient episode. These complications/comorbidities have the potential to change the Episode Clinical Complexity Score (ECCS) (previously known as Patient Clinical Complexity Level (PCCL)) which influences the acuity of the DRG and resulting reimbursement. The ECCS is a measure of the cumulative effect of a patient’s complications and comorbidities and is calculated for each episode of care using the Diagnosis Complexity Level (DCL) value assigned to each diagnosis code (including principal diagnosis) as a complexity weight.Simple checklists or proformas have been shown to improve the accuracy of the principal diagnosis and procedure code resulting in a higher remuneration for the organisation (Clement et al. 2013; Naran et al. 2014; Murphy et al. 2017). Such checklists are completed by the medical team responsible for the patient in hospital. This task is usually delegated to the most junior member of the team. The clinical coding department at the Mater Health Services have developed such checklists for various specialties. The uptake of the use of these checklists during the inpatient stay is variable.This study aims to confirm the increased remuneration achieved by using checklists and to compare the remuneration generated by a junior medical person as compared to a senior doctor using these lists to help with chart reviews.
The World Health Organization Family of International Classifications (WHO-FIC) has a suite of classifications that can be used in an integrated way to collect, compare and report health information at a local, national and international level (Madden et al. 2007). WHO-FIC contains three reference classifications: the International Classification of Diseases (ICD) (World Health Organization 2016), the International Classification of Functioning, Disability and Health (ICF) (World Health Organization 2001)
Residential aged care has recently been in the spotlight in Australia for all the wrong reasons. The Royal Commission into Aged Care Quality and Safety has highlighted many deficiencies in the provision of care (Commonwealth of Australia 2019), and the tragic impact of the COVID-19 pandemic has further laid bare the extent of the failings within the sector. Principal among the contributing factors identified has been insufficient and ineffective funding allocation along with inadequate staffing arrangements.
Health Information Management Awareness Week turned into the Health Information Management Awareness Month in 2019 as the Health Information Management Association of Australia (HIMAA) celebrated the 70 year anniversary of the profession. For the whole month of May our members were busy organising branch events and celebrations, lobby displays, Health Information Services (HIS) department tours and social functions, and making headlines in their health organisations’ newsletters.
When clinical documentation improvement (CDI) was first introduced in the United States (US), it emerged within the policy climate of the Bush administration, with a major focus on increasing the effectiveness of hospital care and reducing the cost of the healthcare system. The Deficit Reduction Act 2005 was a combination of withholding reimbursement (for hospital acquired conditions), assigning mandatory indicators (‘Present on Admission’ flags), and incentivising best practice (through ‘value-based purchasing) (Wilson, 2009). In order to achieve the requirements of the legislation, CDI programs in the US focused on improving the clinical documentation in the medical records so that resultant coded data submitted to internal and external agencies were as complete and accurate as possible, so as to manage the direct impact on reimbursement (Wilson, 2009).
Emergency departments are dedicated hospital-based facilities specifically designed and staffed to provide 24-hour emergency care. The role of the emergency department is to diagnose and treat acute and urgent illnesses and injuries (Independent Hospital Pricing Authority [IHPA] 2019a). Annually, there is an increasing demand on emergency departments in Australian public hospitals. The average emergency department presentation growth from 2013-14 to 2017-18 was 2.7% per annum, which surpasses the average growth of the population over the same period. Total emergency department presentations have increased 11% over the past 5 years, and in the 2017-18 financial year presentations exceeded 8 million (Australian Institute of Health and Welfare [AIHW] 2018a, p.4).
The International Classification of Diseases 11th Revision (ICD-11), was launched by the World Health Organization (WHO) in June 2018. In May 2019, the World Health Assembly adopted ICD-11 for implementation by Member States from 1 January 2022. The WHO will provide transitional arrangements for at least five years from that date, and as long as it is necessary, to support implementation.
In 2013, the Independent Hospital Pricing Authority (IHPA) initiated a review to assess long-term options for the classification of emergency care services for activity-based funding in Australia. A major objective of the approach to classifying emergency care services in Australia was to drive efficiency and effectiveness of these services through pricing and funding.This is underpinned by the collection of data that also support clinical care and other uses such as quality improvement, epidemiological monitoring, and health services research.
Under contract by the Independent Hospital Pricing Authority (IHPA), the Australian Consortium for Classification Development (ACCD)1 has over the last four years been responsible for the development and refinement of the Australian Refined Diagnosis Related Groups Classification System which has two classification components:
- The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), the Australian Classification of Health Interventions (ACHI) and the Australian Coding Standards (ACS)
- Australian Refined Diagnosis Related Groups (AR-DRGs) This report will provide an overview of the development of the Tenth Edition of ICD-10-AM/ACHI/ACS, which was implemented for use in Australian hospitals for clinical coding of admitted episodes from 1 July 2017.
Osteoporosis is recognised as a National Health Priority Area in Australia, owing to the significant burden of associated disease. One in four men and two in five women aged 50 years and over will experience some form of osteoporotic fracture in their lifetime (Australian Institute of Health and Welfare, 2014). These fractures occur after little or no trauma, such as a fall from standing height. They are also known as “minimal trauma” or “low impact” fractures. Osteoporotic fractures are associated with increased morbidity and mortality and risk increases with the number of fractures sustained (Center et al., 2007). With their high prevalence and associated costs, accurate data on health service utilisation for these fractures is important to researchers, policy makers, and hospital managers for planning and resource allocation.The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, AustralianModification (ICD-10-AM) is used to capture the diagnoses in the admitted patient data in Australia. The purpose of this article is to describe the limitations of using ICD-10-AM codes for surveillance of osteoporotic fracture and to encourage discussion of some emerging clinical coding issues.