ICD-10 UK NCCQ Reference Book
Definitions
What is clinical coding? - ANS>>The translation of medical terminology that describes a
patient's complaint, problem, diagnosis or treatment or other reason for seeking medical
attention into codes that can be easily tabulated, aggregated and sorted for statistical
analysis in an efficient and meaningful manner.
FCE - ANS>>Finished Consultant Episode
Local Policies are - ANS>>Agreements reached through local governance on how to
address documentation or recording issues. They are signed off by the clinical director
and/or governance authority. They are regularly reviewed.
Clinical coding audits - ANS>>Work with national clinical coding standards, must be
objective and highlight and promote benefits of taking remedial action to improve data
quality and processes as well as acknowledging evidence of best practice.
Three dimensions of coding accuracy - ANS>>Individual Codes (correct code
assignment for each diagnosis), Totality of Codes (all codes needed to accurately
present the diagnoses are present), and Sequencing of Codes (sequenced according to
coding standards to provide consistent data for statistical analysis).
Coding Uniformity: rules for accurate selection - ANS>>Code the minimum number of
codes to reflect the condition.
Code every condition which affects the care orn influences health status.
Code to the furthest level of specificity.
Do not code background information or chronic problems which are no longer active
and don't influence healthcare being provided in relevant consultant episode.
Step One - ANS>>ANALYSE terminology to determine lead terms and modifiers.
Step Two - ANS>>LOCATE the lead terms in the Alphabetical Index (ICD-10 Volume 3)
Step Three - ANS>>ASSIGN a tentative code using the Alphabetical Index and taking
into account all rules, conventions and standards
Step Four - ANS>>VERIFY the code(s) using the Tabular List (ICD-10 Volume 1) and
taking into account instructional notes.
Rules - ANS>>Apply throughout the classification.
Rules are in grey boxes, explanatory information is in a white box.
Definitions
What is clinical coding? - ANS>>The translation of medical terminology that describes a
patient's complaint, problem, diagnosis or treatment or other reason for seeking medical
attention into codes that can be easily tabulated, aggregated and sorted for statistical
analysis in an efficient and meaningful manner.
FCE - ANS>>Finished Consultant Episode
Local Policies are - ANS>>Agreements reached through local governance on how to
address documentation or recording issues. They are signed off by the clinical director
and/or governance authority. They are regularly reviewed.
Clinical coding audits - ANS>>Work with national clinical coding standards, must be
objective and highlight and promote benefits of taking remedial action to improve data
quality and processes as well as acknowledging evidence of best practice.
Three dimensions of coding accuracy - ANS>>Individual Codes (correct code
assignment for each diagnosis), Totality of Codes (all codes needed to accurately
present the diagnoses are present), and Sequencing of Codes (sequenced according to
coding standards to provide consistent data for statistical analysis).
Coding Uniformity: rules for accurate selection - ANS>>Code the minimum number of
codes to reflect the condition.
Code every condition which affects the care orn influences health status.
Code to the furthest level of specificity.
Do not code background information or chronic problems which are no longer active
and don't influence healthcare being provided in relevant consultant episode.
Step One - ANS>>ANALYSE terminology to determine lead terms and modifiers.
Step Two - ANS>>LOCATE the lead terms in the Alphabetical Index (ICD-10 Volume 3)
Step Three - ANS>>ASSIGN a tentative code using the Alphabetical Index and taking
into account all rules, conventions and standards
Step Four - ANS>>VERIFY the code(s) using the Tabular List (ICD-10 Volume 1) and
taking into account instructional notes.
Rules - ANS>>Apply throughout the classification.
Rules are in grey boxes, explanatory information is in a white box.
