‘Upcoding’ a hazard as PbR pressure grows

Clinical coders are coming under pressure to ‘upcode’ to maximise income under Payment by Results, a conference heard last week.

Sue Eve-Jones, director of the Professional Association of Clinical Coders, told a conference organised by the Health Service Journal in London: “I am being given direct evidence of the pressure on managers who are being asked to code [for activity undertaken] in ways that are not supported by the evidence.” This pressure was being applied to maximise income, she said.

But she added: “In most cases coding mangers are resisting these pressures.”

She gave a number of examples of the sort of practices that coding managers are referring to PACC UK.

“We are seeing patients admitted who would not have been before Payment by Results (PBR). We are seeing ‘virtual wards’ that do not exist but patients near the end of the four hour wait are admitted to them. I believe that this is fraud.”

Her comments come at a time of intensifying debate about gaming and upcoding under PBR. In February the NHS Alliance released a report saying that gaming was widespread with 30 per cent of PCTs they surveyed claiming to have “concrete evidence”.

The definitions of gaming and upcoding remain confused with some commentators using “upcoding” to describe fraudulent behaviour and “gaming” to describe playing the system within legal limits while others reverse these terms.

Last month the Department of Health released its PBR code of conduct that should govern trusts’ behaviour around coding. Ms Eve-Jones said: “If trusts sign up to this it will provide a huge incentive to provide support to coders.”

The Audit Commission is also looking into the issue and currently working on an assurance regime.

Katherine Burchfield, health and policy research manager at the Audit Commission, emphasised that this was not based entirely around policing PBR and gaming.

She said: ‘Everybody recognises that data quality is a major potential benefit but also a major potential risk. PBR has the potential to drive up quality and provide a much richer source of information that helps build clinicians’ interest but also us gives better data.”

She added: “There is no concrete evidence of gaming, that is manipulating length of stay to maximizes income, or discharging from one part of a trust and readmitting to another in order to get two payments instead of one or coding for work that was not carried out.”

However, evidence of these practices did exist in other countries. She said: “Are there sufficient controls in the system in the UK at the moment? No, we do not think there are.”

The assurance regime proposed by the Audit Committee would see a strengthening of the Information Governance Toolkit, which she described as “not fit for purpose”.

It would also see a regular regime of external audit of clinical coding. “We do have audit at the moment but it is not external, it is peer review and it is not fully independent,” she said.

The Audit Commission is now developing benchmarks that would allow PCTs and trusts to compare their short stay admission rates against national benchmarks to test for gaming or anomalies.

Meanwhile, pilot projects for the assurance regime are due to get underway in May. Burchfield said: “If these show that there is any value in developing it we will then develop a programme closely with NHS Connecting for Heath and would hope to see a programme of systematic external audit of coding by 2007.”