News / Audit finds no proof of coding gaming

There is no evidence of systematic gaming under payment by results, according to the Audit Commission’s first PBR clinical coding audit programme.

The programme is part of the data assurance framework and it audited about 50,000 episodes of care, equating to more than £72m of NHS spending during 2007/08.

It found errors in HRG assignment ranged from 0.3% to 52%, with an average error rate of 9.4%. These errors were worth about £3.5m, approximately 5% of the sample reviewed. But the net financial impact was ‘close to zero’, though there were a small number of cases where the financial impact was significant.

‘There is no real evidence of any systematic gaming or upcoding. That’s a good result for the NHS and its values,’ said Andy McKeon, managing director for health at the commission.

Five factors caused errors, including the quality of the source documentation, which was the most commonly-raised issue, and inadequate clinical engagement.

Foundation trusts had marginally lower error rates but the differences were not statistically significant. However, some of the higher error rates were found at specialist trusts, many of which were also FTs – the 52% error rate was at a specialist trust.

The report said specialist trusts’ problems could be because the OPCS and ICD-10 classification systems did not adequately describe their activity. Some may have adopted non-standard classifications because they believed the national systems were inadequate. The commission will further research specialist trust coding later in the year.

Mr McKeon said the audit highlighted wider issues about data quality. Clinical coding error ranged from 1% to 76% and this had a bearing on the wider use of data beyond payment by results.

‘This is an issue that must be addressed, particularly in the light of the Darzi report, with its emphasis on the quality of services provided,’ he said. Measures must be introduced in order to ensure the information used in the quality agenda is reliable.

The commission also called on the Department of Health to review the coding systems and guidance for specialties and HRGs that were prone to error. Training for clinical coders and coding auditors should be improved. There was a link between investment in training and the reduction of errors.