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Friday 28th October 2016

Behind Payment by Results

18th March 2006

Good statistical analysis has always relied on the availability of high quality coded clinical data. But now it is doubly important because clinical coding forms the basis of the new payment by results regime which determines the income a hospital will receive for each patient it treats.

Where data is classified, it should be accurate, consistent and comparable across time and between sources. This is the routine job for clinical coders within a hospital or general practice surgery and the data should be regularly audited to enable confidence in data quality, to provide necessary information for any changes and to make improvements to quality.

There are different levels of coding each having a different purpose:

Terming: At the highest level of detail for recording patient care, often described as the finest granularity, is terming. SNOMED Clinical Terms will provide the building blocks for Electronic Patient Records.

Classifying: The next level is classifying which helps to support statistical and management analysis. These classifications include ICD-10 and OPCS-4. The data must be coded consistently so that it can be compared over time.

Grouping: At a lowest level of detail, a coarser granularity, is the grouping of records together, for example, into Healthcare Resource Groups (HRGs). These are used to support costing and other analysis which studies at a mix of cases or different types of patient care.

Each of the major coding systems is described below: 

SNOWMED Clinical Terms

The Systematised Nomenclature of Medicine Clinical Terms (SNOWMED CT) is a common computerised language of clinical terms for use in clinical practice. It covers areas such as the care and treatment of patients and drugs. It has been a joint development between the NHS and the College of American Pathologists (CAP) and replaces previous versions of clinical terms (Read Codes) and will allow the sharing of health information worldwide.

It will be used by all computers in the NHS and will be the language for the NHS Care Records Service so that healthcare workers can communicate between each other efficiently and consistently knowing that the data from different NHS organisations is comparable.

The Dictionary of Medicines and Devices (dm+d) is being developed by the NHS Connecting for Health and Pricing Prescriptions Authority and contains unique codes and descriptions for all medicines and devices used in the treatment of patients throughout the NHS. The dm+d provides a link to SNOWMED CT used in clinical systems.

Office of Population, Censuses and Surveys – Classification of Surgical Operations and Procedures – 4th Revision (OPCS-4)

All operations and surgical procedures carried out in an acute sector hospital should be translated into an OPCS classification. There are rules and conventions (incorporated within the NHS Clinical Coding Instruction Manual) which ensure that the clinical coder correctly assigns each procedure to the code. The data forms part of the Commissioning Data Set (CDS) and the Hospital Episode Statistics (HES) database. These code lists are continually being updated to ensure that they meet the changing needs of the healthcare providers. OPCS-4.3 just released has been developed to reflect the needs of the Payment by Results (PbR) programme being implemented in 1 April 2006. The classification is arranged in a number of alphabetical chapters representing parts or the whole of a body system and then each chapter contains a numerical three digit code and a description. For example, W596 represents revision of fusion of joint of toe.

International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10)

This classification system developed by the World Health Organisation (WHO) is used to record the reason for a patient’s episode of care. It records diseases and health related problems. As for OPCS-4, the ICD-10 codes are a mandatory part of the CDS and HES database and there are rules and guidelines for assigning the codes to a patient’s record. Again the classification is divided into chapters, for example, infectious and parasitic diseases, which contains, for example, B05 measles, which contains, for example, B052 measles complicated by pneumonia.

The International Classification of Functioning, Disability and Health (ICF)

Also developed by the WHO and launched in 2001, the ICF provides a method of classifying information on the functioning and disability of a patient’s condition and can be used to compliment the ICD-10 code which identifies the disease or condition. The ICF code enables countries to measure the extent of health and disability of a population and the effect on daily lives and enables the WHO to provide a comparative picture of health throughout the world.

International Classification of Health Interventions (ICHI)

This is a third method of classification being developed by the WHO and currently in its beta version. It is intended that this classification will provide a tool for reporting and analysing the evolution and distribution of health interventions.

Healthcare Resource Groups (HRGs)

HRGs are groups of clinical treatments which require similar levels of resource. Each HRG is put into a category 1 to 5 with category 1 using the least resource consumption and category 5 a comparatively higher level. As each HRG requires similar resource usage, it can be used as the basis for costing services. A major revision is currently underway, HRGv4, to support the Payment by Results (PbR) programme.

Useful numbers:

SNOMED Clinical Terms: 01392 206 248

email datastandards@cfh.nhs.uk www.connectingforhealth.nhs.uk/technical/standards/snomed

dm+d: 0845 850 0001

email dmdenquiries@ppa.nhs.uk


OPCS-4.3: 01392 206 248

email datastandards@cfh.nhs.uk


ICD-10: 01392 206 248

email datastandards@cfh.nhs.uk



ICF: email K.Innes@fhs.usyd.edu.au


ICHI: www.who.int/classifications/ichi/en/

HRGs: 0845 300 6016



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