OPCS Classification of Interventions and Procedures Version 4.8 OPCS Classification of Interventions and Procedures Volume I - Tabular List I - Tabular Volume National Clinical Coding Standards OPCS-4 (2017) For more information please visit: Accurate data for quality information systems.digital.nhs.uk/data/clinicalcoding ISBN 978-0-11-323048-8 Clinical Classifications Service www.tso.co.uk 9 780113 230488 9923 OPCS 4.8 Vol I Cover v0_2.indd 1-3 31/10/2016 10:00 National Clinical Coding Standards OPCS-4 Accurate data for quality information Produced by: Clinical Classifications Service NHS Digital Vantage House 40 Aire Street Leeds LS1 4HT [email protected] http://systems.digital.nhs.uk/data/clinicalcoding Date of issue: April 2017 Copyright © 2017 Health and Social Care Information Centre The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. OPCS-4 CONTENTS Introduction ............................................................................................................................ 3 Data Quality ........................................................................................................................... 7 National Clinical Coding Standards OPCS-4 reference book .............................................. 11 Rules of OPCS-4 ................................................................................................................. 16 Conventions of OPCS-4 ...................................................................................................... 24 General Coding Standards and Guidance ........................................................................... 27 Chapter A Nervous System ................................................................................................. 48 Chapter B Endocrine System and Breast ............................................................................ 53 Chapter C Eye ..................................................................................................................... 55 Chapter D Ear...................................................................................................................... 56 Chapter E Respiratory Tract ................................................................................................ 57 Chapter G Upper Digestive Tract ........................................................................................ 60 Chapter H Lower Digestive Tract ......................................................................................... 63 Chapter J Other Abdominal Organs – Principally Digestive ................................................ 65 Chapter K Heart................................................................................................................... 67 Chapter L Arteries and Veins .............................................................................................. 72 Chapter M Urinary ............................................................................................................... 79 Chapter N Male Genital Organs .......................................................................................... 84 Chapter P Lower Female Genital Tract ............................................................................... 85 Chapter Q Upper Female Genital Tract ............................................................................... 86 Chapter R Female Genital Tract Associated with Pregnancy, Childbirth and Puerperium .. 89 Chapter S Skin .................................................................................................................... 93 Chapter T Soft Tissue .......................................................................................................... 99 Chapter U Diagnostic Imaging, Testing and Rehabilitation ............................................... 101 Chapter V Bones and Joints of Skull and Spine ................................................................ 112 Chapter W Other Bones and Joints ................................................................................... 120 Chapter X Miscellaneous Operations ................................................................................ 135 Chapter Y Subsidiary Classification of Methods of Operation ........................................... 148 Chapter Z Subsidiary Classification of Sites of Operation ................................................. 158 Index of Standards ............................................................................................................ 162 Table of Changes .............................................................................................................. 169 2 National Clinical Coding Standards OPCS-4 INTRODUCTION The OPCS Classification of Interventions and Procedures (OPCS-4) is a statistical classification of interventions and procedures undertaken in the National Health Service (NHS) reflecting current clinical practice. OPCS-4 is an approved NHS Fundamental Information Standard. The use of OPCS-4 assumes that: • A patient health record (a medico-legal document) exists, and therefore it is meaningful to have codes that depend on what activity has been specified in that record. • The record is translated and coded, applying the rules, conventions and national standards of the classification, by appropriately trained and qualified clinical coding staff. • Existing data flows are also in place so that when the record is translated and coded, the data can flow from hospital Patient Administration Systems (PAS) and onwards to support local and national data requirements through the Secondary Uses Services (SUS). The classification is mandatory for use by Health Care Providers to support various forms of data collections, such as Central Returns and Commissioning Data Sets (CDS). All Consultant Episodes (hospital provider) containing procedures must be recorded and collected using OPCS-4. The requirements for data sets and related definitions are specified in the NHS Data Model and Data Dictionary. The statistical classification also supports various forms of secondary uses of information essential for planning and improving patient care. Among these secondary uses are: • Operational and strategic planning, • Resource use, • National and local planning and performance management, • Research and epidemiology, • Department of Health initiatives, and • NHS payment system. OPCS-4 is used by NHS suppliers to build or update software to support NHS business functions and interoperability. Background A statistical classification of surgical operations has been available for use in the United Kingdom (UK) since 1944 when the Medical Research Council published one which identified 442 categories of operation. The then General Register Office prepared and 3 Introduction issued an updated version in 1950, and revisions to this were subsequently issued in 1956, (first revision), 1969 (second revision) and 1975 (third revision). This first classification contained 664 un-subdivided three-character categories. It was revised in 1956 with the addition of 10 categories, and again in 1969 at which time the three- character categories were increased to 731. Some of these categories were subdivided (extended to four-character subcategories) so that the classification contained 1183 valid codes. The third revision, in 1975, further expanded the classification to 1426 valid codes. The fourth revision of the OPCS-4 was conceived in 1983 as a result of one of the recommendations in the first report in 1982 of the Steering Group on Health Services Information (SGHSI), chaired by Mrs E Korner. The SGHSI recommended that, “as a matter of urgency, OPCS should provide operation codes, which reflect current clinical practice and develop procedures for the frequent updating of the classification”. The fourth revision of OPCS was initially issued in 1987 with definitive publication and implementation in 1990. The general objectives of the revision process, which began in 1983, were: 1. To identify and classify current surgical operations with particular reference to the incorporation of recent innovative techniques. 2. To eliminate rarely performed operations but to include procedures not requiring the full operating theatre environment. 3. To provide a flexible classification, responsive to less defined specialty boundaries and capable of future expansion. Both the Tabular List and Alphabetical Index were updated in January 1990 and the Alphabetical Index was again revised in April 1993. OPCS-4 then contained 1183 three- character categories all of which were subdivided resulting in over 4000 valid codes. It was originally devised as an instrument to provide the best possible basis for accommodating current systems and future developments for data on surgical operations. As well as maintaining the planned objective, the fourth revision also incorporated two further general aspects. It provided a definition of an operative procedure and outlined the concept of MAIN operation during an episode of care. From 1995 a review of OPCS-4 was completed consulting with users to identify future need and inform future strategic direction. In 2002 a project to develop an up to date intervention classification was commissioned by the Information Policy Unit (IPU). A proposal on behalf of the former NHS Information Authority and the IPU to produce a requirement for the development of a new classification was considered by the Information