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Surviving “Payment by Results”: A simple method of improving clinical coding in burn specialised services in the United Kingdom
burns 35 (2009) 232–236
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Surviving ‘‘Payment by Results’’: A simple method of improving clinical coding in burn specialised services in the United Kingdom Katy L. Wallis a,e,*, Claudia C. Malic b,e, Sonia L. Littlewood c,e, Keith Judkins d,e, Alan R. Phipps e a
Plastic Surgery, St George’s Hospital, London, UK Plastic Surgery, Frenchay Hospital, Bristol, UK c General Surgery, Bradford Royal Infirmary, UK d North of England Burn Care Network, UK e Yorkshire Regional Burns Centre, Pinderfields General Hospital, Aberford Road, Wakefield WF1 4DQ, UK b
article info
abstract
Article history:
Introduction: Coding inpatient episodes plays an important role in determining the financial
Accepted 30 June 2008
remuneration of a clinical service. Insufficient or incomplete data may have very significant consequences on its viability.
Keywords:
We created a document that improves the coding process in our Burns Centre.
Burns
Materials and methods: At Yorkshire Regional Burns Centre an inpatient summary sheet was
Economics
designed to prospectively record and present essential information on a daily basis, for use
Hospital
in the coding process. The level of care was also recorded. A 3-month audit was conducted to
Health expenditures
assess the efficacy of the new forms. Results: Forty-nine patients were admitted to the Burns Centre with a mean age of 27.6 years and TBSA ranging from 0.5% to 65%. The total stay in the Burns Centre was 758 days, of which 22% were at level B3–B5 and 39% at level B2. The use of the new discharge document identified potential income of about GB£ 500,000 at our local daily tariffs for high dependency and intensive care. Conclusion: The new form is able to ensure a high quality of coding with a possible direct impact on the financial resources accrued for burn care. # 2008 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
With the introduction of ‘‘Payment by Results’’ (PbR) in 2003, the United Kingdom’s National Health Service faced dramatic changes in the organisation of its funding. PbR was recognised as a significant financial management challenge for both Primary Care Trusts (PCTs) as purchasers of health care and Hospital Trusts as providers. The main stated aim was to
support patients’ choice and to encourage hospitals to respond to patient preference. It was also intended to provide a fair, consistent and transparent rules-based system for remunerating Trusts for the services they provide and to encourage productivity. In order to sustain this new concept, national tariffs were introduced for healthcare services. Each inpatient episode is assigned to a Healthcare Resource Group (HRG), which attracts a national fixed charge according
* Corresponding author at: 5 Rosewood Avenue, Heaton Mersey, Stockport SK4 2DQ, UK. Tel.: +44 7799140080. E-mail address: [email protected] (K.L. Wallis). 0305-4179/$36.00 # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.06.008
burns 35 (2009) 232–236
to the case mix, and the resources used [1]. Similar classifications are in place in many other countries. The HRG is determined by the coding of a patient’s stay and also by the nature of their admission—elective or emergency. The diagnosis is coded using ICD-10 (International Classification of Diseases Version 10), whereas all surgical procedures performed are coded using OPCS-4 (Office of Population, Censuses and Surveys—Classification of Surgical Operations and Procedures (Version 4)). Locally and nationally, the success of PbR relies upon the collection of accurate data. Accurate coding is vital for the correct HRG to be assigned for each inpatient episode. Due to the nature of some specialised services, not all activities are covered by the tariff and these costs are subject to local negotiation with Health Commissioners. There is also scope to gain reimbursement for certain expensive forms of care with ‘unbundled elements’ (UE), which are paid in addition to the HRG tariff. Burns are highly variable injuries and treatment is individually tailored. Acute burn care services are characterised by relatively low volume, high cost and a caseload primarily of emergency admissions. Optimal management of burns requires a multidisciplinary approach. The resources used include acute and rehabilitation hospital based services, as well as community based services. At present, the complex activity of specialised burn services cannot be accurately assessed under the present HRG or coding system and therefore were included by the Department of Health in the specialised services definition sets. In addition to acute wound management and surgical treatment, the range of services used by burn patients includes: intensive and/or high dependency care, outpatient care, rehabilitation, access to outreach teams, further reconstructive procedures as well as burn camps, patient/parents support groups. Burns HRGs had previously relied heavily on recording the total body surface area (TBSA) affected by thermal injuries. In April 2007, the new HRG (HRG4) included for the first time some aspects of burn pathology which considerably increase the cost of care provided to burns patients such as the diagnosis of full thickness burns, presence of chemical and/or inhalation injury [2]. Previously, these diagnoses were part of the unbundled elements and therefore further funding from the local commissioners was required. To ensure that correct HRGs are assigned for each inpatient stay, all procedures and diagnoses must be accurately captured. Incorrect HRG codes may have significant financial implications for specialised services with a detrimental effect on their sustainability. Therefore, clear documentation is paramount of the diagnoses and all surgical procedures performed, as well as the input of different specialities. Furthermore, the number of such codes is limited for each patient by the capacity of the hospital’s Patient Administration System (PAS), so care must be taken to include only those that are most significant and exclude those that attract no specific remuneration. In the UK, older PAS systems allow up to nine codes; newer systems allow fifteen. At the Yorkshire Regional Burns Centre, our aging PAS system allows only nine which increases the importance of careful selection from meticulous data collection.
2.
233
Method
Our aim was to develop a simple yet comprehensive document which would prompt the capture of all the relevant data about inpatients treated in the Yorkshire Burns Centre, as required for accurate coding for generation of HRGs in the PbR system. A proforma was designed in an A4 format (see Table 1). It aimed to collect information that would highlight relevant diagnoses and procedures performed during an inpatient stay. The hospital used the proforma for coding purposes, and it also served to provide a summary of raw data for efficient production of discharge letters. Patient’s demographic details, aetiology, burn extent and depth, any relevant co-morbidities as well as the presence and extent of inhalation injury were included in the proforma. Inhalation injury was defined as respiratory tract injury requiring ventilatory support in an intensive care setting and categorised as: mild (ventilated for less than 5 days) or severe (ventilation for 5 or more days). In order to capture the level of care that burn patients’ have received on a daily basis, a diary was included to record data in real time throughout the patient’s stay. The level of care used in the diary was as defined by the UK National Burn Care Review Committee (see Table 2) [3]. Change of dressings under sedation is not yet categorised by the coding system as a surgical intervention, and therefore was included in the proforma in order to highlight their unrecognised resource implications. The specific resources utilised during dressing changes were not recorded since the coding system does not support that level of detail. All surgical procedures performed were recorded on the diary card. A further newly designed form was completed for each surgical procedure in an attempt to ease and improve the OPCS coding process (Table 3). The new forms were introduced in our Burns Centre in May 2006 and were completed by medical and nursing staff on a prospective basis, documenting details of all inpatient burn admissions. Three months after the forms were implemented, an audit was carried out in order to investigate the effect of the new proforma on the coding process as well as to perform a remuneration exercise taking into account the various elements of specialised burn care provided in that period of time.
3.
Results
During the 3-month period, 49 patients were admitted to the Yorkshire Regional Burns Centre—36 males and 13 females. Their ages ranged from 4 months to 75 years (18 paediatric and 31 adults). The size of burn varied from 0.25% to 75%TBSA (mean 11%TBSA). The percentage of partial thickness burns varied from 0.5% to 34%TBSA (mean 8%TBSA) and full thickness burns from 0.25% to 65%TBSA (mean 13%TBSA). A total of 7 patients had sustained burns greater than 30%TBSA. Nine of the 49 patients had inhalation injury: one mild and eight severe. Six patients had significant co-morbidities. Fortynine surgical procedures were performed in 25 patients; 32
234
burns 35 (2009) 232–236
Table 1 – Inpatient data collection proforma.
sedation dressing changes were carried out on 9 patients. The number of inpatient days spent at each level of care is shown in Table 4. Under the present system, there is no PbR remuneration for the intensity of care for burn specialised services. Out of a total of 758 days spent in hospital by the 49 patients, fewer than half of them were at B1 level of care and
Table 2 – Nursing levels for monitoring patients with burn injuries (from: National burn care review: committee report 2001 [3]). Type of care B1 B2 B3–B5
Surgical ward High dependency unit Intensive care
Ratio trained staff to patient 0.25:1 0.5:1 1–2:1
166 days were B3–B5 level of care as defined in the National Burn Care Review [3] and summarised in Table 2.
4.
Discussion
This new proforma has provided the Yorkshire Burns Centre with a simple method of documenting important aspects of the multidisciplinary care received by inpatients. Prior to its introduction, many of these elements would have gone unnoticed by the hospital administration and subsequently uncoded, as they were not routinely documented on discharge summaries or not easily identifiable from patients’ notes. Insurance based healthcare systems throughout the world have utilised a similar DRG classification (Diagnosis-Related Groups) since the early 1980s. This classifies patients by
burns 35 (2009) 232–236
235
Table 3 – Surgical procedures proforma.
diagnosis and/or surgical procedure into major diagnostic categories for the purpose of determining payment of hospitalisation charges. This is based on the premise that clinically related patients consume similar resources and thus
generate similar costs. A value is assigned to each group as the basis of payment for all cases in that group, regardless of the actual cost of care provided or the duration of hospital stay for individual patients.
236
burns 35 (2009) 232–236
Table 4 – Number of days per level of care. Level of care.
Days.
Home leavea. B1. B2 complex. B2 non-complex. B3–B5.
50. 243. 91. 206. 166.
a
Patients stepping down from full time inpatient care but not yet suitable for discharge.
Table 5 – Cost of critical care services during study period. Level of care B3–B5 B2 Total
Cost of bed/ day (£)
Number of patient days
Potential revenue (£)
2192 718
166 297
363,872 213,246
–
–
577,118
Several authors have acknowledged the limitations of DRGs in burn care. The DRG categories have been criticised for being too broad, and unrealistic in reflecting the true cost of treating burn patients, particularly in the most severely affected, who consume a much greater proportion of resources [4–6]. Accurate data collection and coding is the cornerstone in achieving accurate HRG generation. Data are coded from a variety of sources such as discharge letters, patients’ notes or other sources, for instance computer based patient record systems. Discharge letters may contain insufficient data, and seeking and finding the relevant information in the patients’ notes is time consuming; computer based systems are dependent on accurate data entry by various members of staff. Coding check sheets and electronic documentation have been shown to increase the accuracy of coding within Burns Centres, with a direct effect on billing for inpatient care [7,8]. It is imperative for Burns Centre in the UK to adapt to the new PbR system and collect appropriate and accurate data, which may not have been routinely captured previously. Critical care elements are a prime example of this. Prior to the introduction of the discharge proforma in the Yorkshire Burns Centre, the number of days spent by patients in each level of care was not clearly recorded. With the introduction of specific payment for Burns Critical Care, clear documentation is a necessity. Previously, intensive and high dependency care services were funded and commissioned on a block allocation basis and the cost per day per bed varied across the United Kingdom. For the financial year 2007–2008, Burns ICU care is excluded from intensive care shadowing, although a critical care minimum data set is being collected in UK intensive care units including those that treat burns to inform development of a critical care payment system for PbR. Had our burn service been remunerated under the previous local arrangements for the funding of intensive care services (Table 5), the sum involved would be in the region of half a million pounds for
this 3-month period. Over the course of a year this extrapolates to a potential income loss of up to 2 million pounds if these episodes had not been properly coded. Burns are low volume high cost injuries and as such, are difficult to capture in standardised tariffs. The current limitations of the HRG system are acknowledged and are being continually updated with assistance from clinicians. Centralised data collection from the Burns Centre by the British Isles Burn Injury Database (BIBID) will be helpful in deriving reference costs so that future tariffs within PbR can more accurately represent the actual cost of patients’ care. This will be assisted by further development of ICD and OPCS codes as well as refining future HRGs. Nevertheless, however well the system is refined and tailored to the complexities of modern burn care, accurate recovery of funding for patients treated will stand or fall on the accuracy of the detail fed into clinical coding.
5.
Conclusions
In the new financial era of ‘‘Payment by Results’’ in the United Kingdom NHS, it is essential that all specialised services provided within the burn services are accurately recorded and coded. Without appropriate financial reimbursement a tertiary burns service cannot be sustained. We have developed a simple tool that assists accurate coding of burn inpatient stay in the UK financial environment. We are confident that this will enable us to adapt as the payment system develops to ensure consistent funding for our service.
Conflict of interest None.
references
[1] Payment by results guidance 2007–2008. Department of Health; 2006. [2] Introduction to chapter JB: burns procedures and disorders. The Information Centre, Casemix Service; 2007. [3] Standards and strategy for burn care: a review of burn care in the British Isles. National burn care review: committee report. British Burns Association; 2001. [4] Dimick AR, Potts LH, Charles ED, et al. The cost of burn care and implications for the future on quality of care. J Trauma 1986;26(3):260–6. [5] Hunt JL, Purdue GF. Cost containment/cost reduction: the economic impact of burn DRGs. J Burn Care Rehabil 1986;7(5):417–21. [6] Sharkey PD, Horn SD, Brigham PA, et al. Classifying patients with burns for hospital reimbursement: Diagnosis-Related Groups and modifications for severity. J Burn Care Rehabil 1991;12(4):319–29. [7] Maxwell G, Silverstein P. Burn centre reimbursement analysis. J Burn Care Rehabil 1992;13(5):597–9. [8] Heistein JB, Coffey RA, Buchele BA, et al. Development and inititation of computer generated documentation for burn patient care. J Burn Care Rehabil 2002;23(4):273–9.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Surviving ‘‘Payment by Results’’: A simple method of improving clinical coding in burn specialised services in the United Kingdom Katy L. Wallis a,e,*, Claudia C. Malic b,e, Sonia L. Littlewood c,e, Keith Judkins d,e, Alan R. Phipps e a
Plastic Surgery, St George’s Hospital, London, UK Plastic Surgery, Frenchay Hospital, Bristol, UK c General Surgery, Bradford Royal Infirmary, UK d North of England Burn Care Network, UK e Yorkshire Regional Burns Centre, Pinderfields General Hospital, Aberford Road, Wakefield WF1 4DQ, UK b
article info
abstract
Article history:
Introduction: Coding inpatient episodes plays an important role in determining the financial
Accepted 30 June 2008
remuneration of a clinical service. Insufficient or incomplete data may have very significant consequences on its viability.
Keywords:
We created a document that improves the coding process in our Burns Centre.
Burns
Materials and methods: At Yorkshire Regional Burns Centre an inpatient summary sheet was
Economics
designed to prospectively record and present essential information on a daily basis, for use
Hospital
in the coding process. The level of care was also recorded. A 3-month audit was conducted to
Health expenditures
assess the efficacy of the new forms. Results: Forty-nine patients were admitted to the Burns Centre with a mean age of 27.6 years and TBSA ranging from 0.5% to 65%. The total stay in the Burns Centre was 758 days, of which 22% were at level B3–B5 and 39% at level B2. The use of the new discharge document identified potential income of about GB£ 500,000 at our local daily tariffs for high dependency and intensive care. Conclusion: The new form is able to ensure a high quality of coding with a possible direct impact on the financial resources accrued for burn care. # 2008 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
With the introduction of ‘‘Payment by Results’’ (PbR) in 2003, the United Kingdom’s National Health Service faced dramatic changes in the organisation of its funding. PbR was recognised as a significant financial management challenge for both Primary Care Trusts (PCTs) as purchasers of health care and Hospital Trusts as providers. The main stated aim was to
support patients’ choice and to encourage hospitals to respond to patient preference. It was also intended to provide a fair, consistent and transparent rules-based system for remunerating Trusts for the services they provide and to encourage productivity. In order to sustain this new concept, national tariffs were introduced for healthcare services. Each inpatient episode is assigned to a Healthcare Resource Group (HRG), which attracts a national fixed charge according
* Corresponding author at: 5 Rosewood Avenue, Heaton Mersey, Stockport SK4 2DQ, UK. Tel.: +44 7799140080. E-mail address: [email protected] (K.L. Wallis). 0305-4179/$36.00 # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.06.008
burns 35 (2009) 232–236
to the case mix, and the resources used [1]. Similar classifications are in place in many other countries. The HRG is determined by the coding of a patient’s stay and also by the nature of their admission—elective or emergency. The diagnosis is coded using ICD-10 (International Classification of Diseases Version 10), whereas all surgical procedures performed are coded using OPCS-4 (Office of Population, Censuses and Surveys—Classification of Surgical Operations and Procedures (Version 4)). Locally and nationally, the success of PbR relies upon the collection of accurate data. Accurate coding is vital for the correct HRG to be assigned for each inpatient episode. Due to the nature of some specialised services, not all activities are covered by the tariff and these costs are subject to local negotiation with Health Commissioners. There is also scope to gain reimbursement for certain expensive forms of care with ‘unbundled elements’ (UE), which are paid in addition to the HRG tariff. Burns are highly variable injuries and treatment is individually tailored. Acute burn care services are characterised by relatively low volume, high cost and a caseload primarily of emergency admissions. Optimal management of burns requires a multidisciplinary approach. The resources used include acute and rehabilitation hospital based services, as well as community based services. At present, the complex activity of specialised burn services cannot be accurately assessed under the present HRG or coding system and therefore were included by the Department of Health in the specialised services definition sets. In addition to acute wound management and surgical treatment, the range of services used by burn patients includes: intensive and/or high dependency care, outpatient care, rehabilitation, access to outreach teams, further reconstructive procedures as well as burn camps, patient/parents support groups. Burns HRGs had previously relied heavily on recording the total body surface area (TBSA) affected by thermal injuries. In April 2007, the new HRG (HRG4) included for the first time some aspects of burn pathology which considerably increase the cost of care provided to burns patients such as the diagnosis of full thickness burns, presence of chemical and/or inhalation injury [2]. Previously, these diagnoses were part of the unbundled elements and therefore further funding from the local commissioners was required. To ensure that correct HRGs are assigned for each inpatient stay, all procedures and diagnoses must be accurately captured. Incorrect HRG codes may have significant financial implications for specialised services with a detrimental effect on their sustainability. Therefore, clear documentation is paramount of the diagnoses and all surgical procedures performed, as well as the input of different specialities. Furthermore, the number of such codes is limited for each patient by the capacity of the hospital’s Patient Administration System (PAS), so care must be taken to include only those that are most significant and exclude those that attract no specific remuneration. In the UK, older PAS systems allow up to nine codes; newer systems allow fifteen. At the Yorkshire Regional Burns Centre, our aging PAS system allows only nine which increases the importance of careful selection from meticulous data collection.
2.
233
Method
Our aim was to develop a simple yet comprehensive document which would prompt the capture of all the relevant data about inpatients treated in the Yorkshire Burns Centre, as required for accurate coding for generation of HRGs in the PbR system. A proforma was designed in an A4 format (see Table 1). It aimed to collect information that would highlight relevant diagnoses and procedures performed during an inpatient stay. The hospital used the proforma for coding purposes, and it also served to provide a summary of raw data for efficient production of discharge letters. Patient’s demographic details, aetiology, burn extent and depth, any relevant co-morbidities as well as the presence and extent of inhalation injury were included in the proforma. Inhalation injury was defined as respiratory tract injury requiring ventilatory support in an intensive care setting and categorised as: mild (ventilated for less than 5 days) or severe (ventilation for 5 or more days). In order to capture the level of care that burn patients’ have received on a daily basis, a diary was included to record data in real time throughout the patient’s stay. The level of care used in the diary was as defined by the UK National Burn Care Review Committee (see Table 2) [3]. Change of dressings under sedation is not yet categorised by the coding system as a surgical intervention, and therefore was included in the proforma in order to highlight their unrecognised resource implications. The specific resources utilised during dressing changes were not recorded since the coding system does not support that level of detail. All surgical procedures performed were recorded on the diary card. A further newly designed form was completed for each surgical procedure in an attempt to ease and improve the OPCS coding process (Table 3). The new forms were introduced in our Burns Centre in May 2006 and were completed by medical and nursing staff on a prospective basis, documenting details of all inpatient burn admissions. Three months after the forms were implemented, an audit was carried out in order to investigate the effect of the new proforma on the coding process as well as to perform a remuneration exercise taking into account the various elements of specialised burn care provided in that period of time.
3.
Results
During the 3-month period, 49 patients were admitted to the Yorkshire Regional Burns Centre—36 males and 13 females. Their ages ranged from 4 months to 75 years (18 paediatric and 31 adults). The size of burn varied from 0.25% to 75%TBSA (mean 11%TBSA). The percentage of partial thickness burns varied from 0.5% to 34%TBSA (mean 8%TBSA) and full thickness burns from 0.25% to 65%TBSA (mean 13%TBSA). A total of 7 patients had sustained burns greater than 30%TBSA. Nine of the 49 patients had inhalation injury: one mild and eight severe. Six patients had significant co-morbidities. Fortynine surgical procedures were performed in 25 patients; 32
234
burns 35 (2009) 232–236
Table 1 – Inpatient data collection proforma.
sedation dressing changes were carried out on 9 patients. The number of inpatient days spent at each level of care is shown in Table 4. Under the present system, there is no PbR remuneration for the intensity of care for burn specialised services. Out of a total of 758 days spent in hospital by the 49 patients, fewer than half of them were at B1 level of care and
Table 2 – Nursing levels for monitoring patients with burn injuries (from: National burn care review: committee report 2001 [3]). Type of care B1 B2 B3–B5
Surgical ward High dependency unit Intensive care
Ratio trained staff to patient 0.25:1 0.5:1 1–2:1
166 days were B3–B5 level of care as defined in the National Burn Care Review [3] and summarised in Table 2.
4.
Discussion
This new proforma has provided the Yorkshire Burns Centre with a simple method of documenting important aspects of the multidisciplinary care received by inpatients. Prior to its introduction, many of these elements would have gone unnoticed by the hospital administration and subsequently uncoded, as they were not routinely documented on discharge summaries or not easily identifiable from patients’ notes. Insurance based healthcare systems throughout the world have utilised a similar DRG classification (Diagnosis-Related Groups) since the early 1980s. This classifies patients by
burns 35 (2009) 232–236
235
Table 3 – Surgical procedures proforma.
diagnosis and/or surgical procedure into major diagnostic categories for the purpose of determining payment of hospitalisation charges. This is based on the premise that clinically related patients consume similar resources and thus
generate similar costs. A value is assigned to each group as the basis of payment for all cases in that group, regardless of the actual cost of care provided or the duration of hospital stay for individual patients.
236
burns 35 (2009) 232–236
Table 4 – Number of days per level of care. Level of care.
Days.
Home leavea. B1. B2 complex. B2 non-complex. B3–B5.
50. 243. 91. 206. 166.
a
Patients stepping down from full time inpatient care but not yet suitable for discharge.
Table 5 – Cost of critical care services during study period. Level of care B3–B5 B2 Total
Cost of bed/ day (£)
Number of patient days
Potential revenue (£)
2192 718
166 297
363,872 213,246
–
–
577,118
Several authors have acknowledged the limitations of DRGs in burn care. The DRG categories have been criticised for being too broad, and unrealistic in reflecting the true cost of treating burn patients, particularly in the most severely affected, who consume a much greater proportion of resources [4–6]. Accurate data collection and coding is the cornerstone in achieving accurate HRG generation. Data are coded from a variety of sources such as discharge letters, patients’ notes or other sources, for instance computer based patient record systems. Discharge letters may contain insufficient data, and seeking and finding the relevant information in the patients’ notes is time consuming; computer based systems are dependent on accurate data entry by various members of staff. Coding check sheets and electronic documentation have been shown to increase the accuracy of coding within Burns Centres, with a direct effect on billing for inpatient care [7,8]. It is imperative for Burns Centre in the UK to adapt to the new PbR system and collect appropriate and accurate data, which may not have been routinely captured previously. Critical care elements are a prime example of this. Prior to the introduction of the discharge proforma in the Yorkshire Burns Centre, the number of days spent by patients in each level of care was not clearly recorded. With the introduction of specific payment for Burns Critical Care, clear documentation is a necessity. Previously, intensive and high dependency care services were funded and commissioned on a block allocation basis and the cost per day per bed varied across the United Kingdom. For the financial year 2007–2008, Burns ICU care is excluded from intensive care shadowing, although a critical care minimum data set is being collected in UK intensive care units including those that treat burns to inform development of a critical care payment system for PbR. Had our burn service been remunerated under the previous local arrangements for the funding of intensive care services (Table 5), the sum involved would be in the region of half a million pounds for
this 3-month period. Over the course of a year this extrapolates to a potential income loss of up to 2 million pounds if these episodes had not been properly coded. Burns are low volume high cost injuries and as such, are difficult to capture in standardised tariffs. The current limitations of the HRG system are acknowledged and are being continually updated with assistance from clinicians. Centralised data collection from the Burns Centre by the British Isles Burn Injury Database (BIBID) will be helpful in deriving reference costs so that future tariffs within PbR can more accurately represent the actual cost of patients’ care. This will be assisted by further development of ICD and OPCS codes as well as refining future HRGs. Nevertheless, however well the system is refined and tailored to the complexities of modern burn care, accurate recovery of funding for patients treated will stand or fall on the accuracy of the detail fed into clinical coding.
5.
Conclusions
In the new financial era of ‘‘Payment by Results’’ in the United Kingdom NHS, it is essential that all specialised services provided within the burn services are accurately recorded and coded. Without appropriate financial reimbursement a tertiary burns service cannot be sustained. We have developed a simple tool that assists accurate coding of burn inpatient stay in the UK financial environment. We are confident that this will enable us to adapt as the payment system develops to ensure consistent funding for our service.
Conflict of interest None.
references
[1] Payment by results guidance 2007–2008. Department of Health; 2006. [2] Introduction to chapter JB: burns procedures and disorders. The Information Centre, Casemix Service; 2007. [3] Standards and strategy for burn care: a review of burn care in the British Isles. National burn care review: committee report. British Burns Association; 2001. [4] Dimick AR, Potts LH, Charles ED, et al. The cost of burn care and implications for the future on quality of care. J Trauma 1986;26(3):260–6. [5] Hunt JL, Purdue GF. Cost containment/cost reduction: the economic impact of burn DRGs. J Burn Care Rehabil 1986;7(5):417–21. [6] Sharkey PD, Horn SD, Brigham PA, et al. Classifying patients with burns for hospital reimbursement: Diagnosis-Related Groups and modifications for severity. J Burn Care Rehabil 1991;12(4):319–29. [7] Maxwell G, Silverstein P. Burn centre reimbursement analysis. J Burn Care Rehabil 1992;13(5):597–9. [8] Heistein JB, Coffey RA, Buchele BA, et al. Development and inititation of computer generated documentation for burn patient care. J Burn Care Rehabil 2002;23(4):273–9.