Medical Coding in Uk - Read Thesaurus

The Read Thesaurus is an all-inclusive, clinical coding vocabulary that evolved from early versions of the less complex Read Codes medical coding scheme. In the beginning, the primary source of input was derived from the general experience and expertise of healthcare professionals in the United Kingdom. However, the modern Read Thesaurus utilizes an advanced template table that incorporates a range of standardized functions, including a definition of concepts that revolves around object-attribute-value triples.

In a report prepared by the National Health Service Centre for Coding and Classification out of Loughborough, United Kingdom, the authors state that over 50% of the surgical procedures recorded in the Read Thesaurus display attributes that fall into a fully definable concept field. By distinguishing between concepts and terms, the Thesaurus makes use of alphanumeric identifiers. This provides support for multiple classifications that enable a flexibility that places each concept into a hierarchy defined as a directed acrylic graph.

Now what is the value of all this technical language?

The end result of the Read Thesaurus promotes the large-scale application of the European model for a user-defined medical coding terminology. Surgical procedures are essentially a form of structured human intervention that involves a prescribed series of attributes. Success of the procedures can be greatly increased by the surgeon's understanding of those attributes. Thus, in the larger format of medical coding, the ultimate goal is focused upon better and safer patient healthcare. By having a method that successfully enables the sharing of information between different European languages and classification structures, the surgical procedure can be represented in a manner that supports a range of computerized, clinical terminology applications.

Now the system expands reaching into the areas of diagnosis classifications, disease control, and other health care treatment settings. The names and titles shift and change, but the principles of the Read Thesaurus, and other medical coding formats, continue to revolve around the use of alpha and numeric digits and full code titles.

Expected sub-divisions such as the distinctions between procedure classifications systems and diagnosis classification systems will occur, but the fundamental pattern of medical coding remains established. The depth of concept expands, and the coding system is enlarged to handle greater variety. We shift from a 3 or 4-digit numeric system to a 7-character alpha or numeric system. Likewise, the human requirements of skill, training, and depth of knowledge for accurate application also increase.

The depth of current medical knowledge generates a consistent change in terminology that quickly outdates codes, and that produces inaccurate and limited data. The information fails to remain current or consistent with modern medical practices. This sometimes leaves us with the inability to accurately describe the diagnoses and inpatient procedures that best fit the patient's healthcare needs.

How are we handling the shortfalls?

New coding methods are now available, methods that show more specific clinical information such as pressure and location details, mechanical complications, and angioplasty codes. Modern medical coding includes:

· Enhanced surveillance and public health details
· Better health care measurement ratings
· Advanced sensitivity to refined grouping and reimbursement methodologies
· A greater reduction in the need for collaboration documentation
· Updated classification of diseases
· Current medical terminology
· Code comparison structures that enable cross links between mortality and morbidity data
· Improved data lines for processing claims, identifying abuse, designing current payment systems, reducing fraud, measuring the quality of patient care, and tracking public health issues.

The value of retaining an up-to-date medical coding system cannot be understated. When planning for the implementation of new medical coding procedures, remember the following points:

· Analyze the current situation
· Identify the areas and parties that will be affected
· Be careful to assess the full impact of change
· Formulate an approach and clearly defines the goals
· Consider the various levels of educational and retraining that will be involved
· Setup an advance information technology game plan that incorporates an active testing stage aîd a realistic “go live” date
· Prepare advanced documentation that fully incorporates the planed changes and who they will affect

Finally, you must look at maintaining strategic control of the update. Start by establishing a clear set of objectives. Determine and acquire the necessary plan measurement tools. Plan out the best means of evaluating the change over, and then implement the strategies that best support that plan.

The tools are in place. Current medical coding software is quick and efficient. Make the right decisions to stay on top of this ever-changing technology.