GIRFT Clinical Leads - Coding consultation

Closed 21 Oct 2019

Opened 10 Oct 2019


This survey should take around 2 minutes and has only 4 yes/no questions.

There are two small but important areas of clinical coding variation that compromise the usefulness of coded data in some circumstances. There are variations in:

  1. Obesity diagnosis code assignment
  2. Coding of non-definitive diagnostic statements

The paper attached below (please scroll to the bottom of the page) describes the reasons for the variation and proposes improvements in national coding standards to reduce the variation. The information in this paper can also be found on each question page within this survey for ease of access.

In summary, the 2 proposals are:

1. Obesity should be added to the mandatory comorbidities clinical coding list. The BMI score should be used to assign clinical codes for obesity (where relevant), with standardised clinical codes assigned based on BMI score ranges.

2. Change the clinical coding national standards so that when “likely” is used in the clinical record to qualify a diagnostic term, it is treated by coders as having the same meaning as “probable”.

Why We Are Consulting

The purpose of this short survey is to confirm that the proposals make clinical sense.