Introduction Whipps Cross Hospital is a 730 bed district general hospital in North East London that generates circa £1,000,000 revenue per annum from approximately 250 ERCP procedures. ERCPs are complex endoscopic procedures with remuneration dependent on both patient and procedural factors (from £723 to over £7283). Innacurate coding leads to a decrease in remuneration.

For example, the insertion of a metal stent with sphincterotomy generates one of three tariffs: £948 (if length of stay (LOS) is ≤2 days), £4443 (if LOS≥3 without major comorbidities), and £7283 (if LOS≥3 days with major comorbidities (eg. sepsis, dementia or renal failure)). However not coding the sphincterotomy would lead to a decrease in remuneration to £909, £4453 and £6771 respectively, and coding the metal stent as plastic would also lead to a decrease in remuneration (£848, £3532 and £5532).

Following a fall in annual remuneration despite an increase in procedure volume and complexity, an eight month quality improvement project (QIP) was commenced to evaluate and improve the situation.

Method Procedures were identified from the unisoft database. For each patient the coding summary, co-morbidities and LOS were retrieved from Cerner Millennium. Using these data a senior gastroenterologist determined the expected remuneration based upon patient and procedural factors. These figures were then compared to the actual ‘coded’ remuneration (%remuneration). In addition the% of procedures with coding discrepancies were recorded.

Following a four month retrospective benchmark audit our QIP identified a number of areas to be improved: using a dedicated and trained ERCP coder, clearer procedural documentation, and protocols to ensure that all procedures were coded.

Results Our benchmark audit identified a deficit of £35 534 in coded activity, equivalent to a remuneration of 85%.

We have now completed 3 PDSA cycles. The first two show month-on-month improvements with reduced procedures with discrepant coding, and an improvement in remuneration. Cycle 3 was carried out without a dedicated coder to evaluate the significance of this change. The marked fall in both outcome measures highlights the importance of this intervention.

Conclusion This project has identified a potential £1 50 000 shortfall (15%) in annual income from ERCP. Our interventions have already identified a number of areas that have improved coding accuracy and remuneration. We suspect these problems will be ubiquitous and would recommend similar projects to be carried out at other centres providing ERCP.

Disclosure of Interest None Declared