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Coding Clinic Is the Technical Supplement Providing New and Updated Guidance Or Clinical Coding Standards for ICD-10 and OPCS-4

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Coding Clinic Is the Technical Supplement Providing New and Updated Guidance Or Clinical Coding Standards for ICD-10 and OPCS-4 The Coding Clinic is the technical supplement providing new and updated guidance or clinical coding standards for ICD-10 and OPCS-4. The Terminology and Classifications Delivery Service is the definitive source of national clinical coding standards and guidance for ICD-10 and OPCS-4 classifications used by the NHS. Version 7.0 Latest release: April 2018 Coding Clinic Latest release: April 2018 [V7.0] Public sector information is available under the terms of the Open Government Licence: http://www.nationalarchives.gov.uk/doc/open-government-licence/ ICD-10 codes, terms and text used by permission of WHO, from: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, 5th Edition, 2016 (ICD-10). Vols 1-3. Geneva, World Health Organization, 1992-2016. How to attribute this document: Coding Clinic, Terminology and Classifications Delivery Service https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=298579 The Coding Clinic is produced by: Terminology and Classifications Delivery Service NHS Digital Vantage House 40 Aire Street Leeds LS1 4HT [email protected] https://digital.nhs.uk/article/290/Terminology-and-Classifications Latest release: April 2018 [V7.0] First released: December 2011 [V1.0] Clinical coding queries can be submitted to the Terminology and Classifications Delivery Service: https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=298739&exp=e1 Send your feedback on the Coding Clinic to: [email protected] Copyright © 2018 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. i Coding Clinic Latest release: April 2018 [V7.0] Table of Contents Introduction ........................................................................................................................ iii Coding Clinic format .......................................................................................................... iv User instructions ................................................................................................................ v List of guidance.................................................................................................................... 1 ii Coding Clinic Latest release: April 2018 [V7.0] Introduction From 2011 the Coding Clinic, published by the Terminology and Classifications Delivery Service, is released as a single compendium of latest national clinical coding standards, guidance associated with ICD-10 and OPCS-4 classifications and more general information published between releases of the OPCS-4 and ICD-10 National Clinical Coding Standards reference books. Information that is considered to be a national standard or guidance is incorporated into the next release of the OPCS-4 or ICD-10 National Clinical Coding Standards reference books and subsequently removed from the Coding Clinic. The Terminology and Classifications Delivery Service is the definitive source of national clinical coding standards and guidance and issues all national standards associated with ICD-10 and OPCS-4 to be followed by the NHS. As coded clinical information is regularly exchanged within and around NHS organisations, the application of uniform standards as to how the data is recorded is crucial to ensure consistency and comparability. Updates to clinical coding standards and guidance are necessary to keep pace with changing health care practice and information needs. The purpose of the Coding Clinic is to provide: • guidelines on queries that relate to classification/coding issues which require national clinical coding standards to be clarified, modified or developed • information on new diagnoses/procedures and interventions that have significant impact on data users • educational/technical theory and practical examples of clinical coding classification rules and conventions, national clinical coding standards and changes to those standards for both input and output users • additional information and updates to the OPCS-4 and ICD-10 National Clinical Coding Standards reference books in between each release. The Coding Clinic is primarily aimed at clinical coders recording patient diagnostic and interventional/procedural information using the ICD-10 and OPCS-4 classifications to provide notification of developments in national coding standards and guidance. Background Between November 1992 and March 2011 92 issues of the Coding Clinic were released, containing over 600 individual items of clinical coding guidance and national standards. The Coding Clinics together formed the Coding Clinic Collection. Over time information was superseded or updated either in a later Coding Clinic issue, in the Clinical Coding Instruction Manuals, or by updates to the OPCS-4 and ICD-10 classifications. iii Coding Clinic Latest release: April 2018 [V7.0] During 2010-11 the Terminology and Classifications Delivery Service completed a major review of the Coding Clinic Collection to consolidate current information and improve the publication format. Coding Clinic format The Coding Clinic is published as one PDF document in electronic format. You can create an internet browser shortcut for easy access to the latest Coding Clinic: https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=298579 Alternatively, each new release can be downloaded onto your computer (deleting the previous release from your computer first). We also recommend you subscribe to our mailing list to receive notification of the latest update, see Bulletins below. To obtain maximum benefit of the features provided in the electronic version of this PDF document we recommend that you access the electronic version rather than printing a hard copy. Because of the logical methods for adding new guidance and superseding or updating existing guidance (explained in more detail below) the Coding Clinic content and page numbering will be different with each release. You will find that maintaining a consistently accurate and up-to-date hard copy is not practical. Therefore we advise caution if you choose to maintain a hard copy rather than download the latest version of the Coding Clinic. Key features • Electronic form of the PDF document allows quick access to all information held in one place • Table of Contents and bookmarks area have hyperlinks for easy navigation and retrieval of information • Guidance has a unique identifier for reference purposes • Information will be updated in a logical and consistent manner • Update history for each updated item of guidance allows an audit trail of amendments • Updated guidance is highlighted in each release so that it is easily recognisable • Annex of deleted guidance is available for historical reference iv Coding Clinic Latest release: April 2018 [V7.0] Bulletins Guidance will be released in the Coding Clinic as required. Each time the Coding Clinic is released a bulletin will be emailed to subscribers of the Terminology and Classifications newsletter, giving notification of the new release. To ensure you access the latest information you can register to receive these alerts by signing up to our mailing list. User instructions All changes made to a Coding Clinic release (guidance added, updated, superseded or deleted) will be identified to ensure that the user is aware of any changes to guidance and national standards that they must apply. This will also avoid the user having to look through the whole document at guidance that remains the same. To identify these changes the title of the guidance in the List of Guidance and in the bookmarks area is displayed in red typeface. The guidance text box is surrounded with a red border to ensure ease of identification. The red titles and borders indicate that the guidance has been subject to change in that particular release. In the next release the red text and borders will revert to normal formatting. The Version number will be updated each time a Coding Clinic is released. Layout of the Coding Clinic Coding Clinic guidance is grouped into six sections; within each section guidance is listed in publication date/deletion date order; newest to oldest. The sections are: List of Guidance This is a list of the guidance contained within the Coding Clinic. Either; select the title of the guidance in this list, or in the bookmarks area, to be taken directly to the selected guidance. Section 1: ICD-10 Guidance This section contains all current ICD-10 guidance. Section 2: OPCS-4 Guidance This section contains all current OPCS-4 guidance. Section 3: ICD-10 and OPCS-4 guidance This section contains current guidance which provides information on ICD-10 and OPCS-4 classifications within the same item. v Coding Clinic Latest release: April 2018 [V7.0] Annex A: Deleted guidance Annex A contains deleted and superseded Coding Clinic guidance. See Deleted guidance and Superseded guidance below. This section has been included to provide a library of deleted guidance for access by those who wish to perform historic data analysis using previous guidance. Annex B: Consolidated guidance Annex B contains tables detailing all Coding Clinic guidance that has been consolidated into the current OPCS-4 or ICD-10 National Clinical Coding Standards reference books. See Consolidated guidance below. Navigating the Coding Clinic The Coding Clinic is easily navigable using the bookmarks area displayed on the left of the document. By selecting a heading, in the bookmarks area, you are taken directly to the heading within the Coding
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