Data Quality Assurance

Definitions of Error Types

Major and Minor Errors
Major errors are so described because they are more likely to have an adverse effect on the subsequent value of the data than minor (or 'partial') errors. Major and minor errors in clinical coding may also be described as 3-digit level and 4-digit level errors respectively.

Errors in Clinical Coding
Main Condition and Other Conditions; Main Operation and Other Operations

Major or 3-digit level errors - (error codes N or M)

• a condition/operation coded using an incorrect 3-digit ICD10/OPCS4 category
• a condition/operation which should have been coded but was omitted
• a main condition/main operation (DG1/OP1) coded correctly to at least 3-digit level, but the code incorrectly positioned in Other Conditions/Other Operations (DG2-6/OP2-4)
• a condition/operation unnecessarily recorded - over-recording

Minor or 4-digit level errors - (error code P)

• a condition coded using the correct 3-digit ICS10 category but with incorrect 4th or 5th digit
• a coded diagnoses which had not been formatted in a dagger and asterisk pair code when appropriate
• an operation coded in the correct 3-digit OPCS4 category but with an incorrect 4th digit
• an operation coded using the correct 3-digit OPCS4 category but with incorrect/omitted supplementary (e.g. site or laterality code)
• a coded operation which has not been formatted in a pair code when appropriate

Note
• 3-digit level coding accuracy rates reflect only major clinical coding errors
• 4-digit level coding accuracy rates reflect both major and minor clincal coding errors

Errors in Other Assessed Data Items
Consultant/HCP responsible for care, Clinician responsible for main operation
• Any incorrect code recorded for these items, or no coded recorded when required is regarded as a major error (N)

Waiting List Date, Date of Main Operation
• Errors in Waiting List Date or Date of Main Operation which are less than 2 days in error are regarded as a minor error (P)
• Errors in Waiting List Date or Date of Main Operation which are more than 2 days in error are regarded as a major error (N)

Accuracy Not Known - (error code B and D)
Sometimes when assessing an SMR data item in a particular record, DQA are unable to find recorded evidence either to confirm the value recorded or to show it to be incorrect, such data items are scored as "accuracy not known" and are excluded from the calculations.

Occasionally it is possible to find evidence to support the use of a clinical code at 3-digit level without finding any evidence regarding the accuracy of the coding at 4-digit level.  In such cases it is recorded with error code D and the record is included in the 3-digit accuracy calculations for the particular data item, but excluded from the 4-digit level calculations.

Main contact: Margaret Mason

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