When reconfiguring the muscle biopsy service at our hospital, it became apparent that the referral form used was inadequate. The clinical information acquired was minimal. The form did not comply with National Coding practice.¹ The absence of good clinical information could negatively affect the neuropathological diagnosis and income generated by the muscle biopsy service. Therefore, in collaboration with Neuropathology and Clinical Coding, we developed a new form to capture relevant clinical and coding information. To determine the impact of the new referral form, we undertook a quality improvement project.

Forty muscle biopsies (2012–2016) were selected at random from the Neuropathology archives. The notes were reviewed and used to complete the new referral form. Using this information, the coding and tariffs were reassessed and compared to those produced using the original referral form. Prospective data from muscle biopsy cases (01–06/2018) were also analysed.

Results demonstrated a significant improvement in quality of documentation supplied to Clinical Coding and increased diagnostic usefulness for Neuropathology. Although the new form has significantly helped the Clinical Coding team, with a simpler and more efficient coding outline that has reached National Coding Standards¹, it had little impact on the income generated.

References

1. ‘National Clinical Coding Standards ICD-10 5th Edition 2017 -https://hscic.kahootz.com/gf2.ti/f/762498/27838213.1/PDF/-/NCCSICD102017.pdf