National Clinical Coding Training Handbook: Terminology Andclassifications Delivery Service
National Clinical Coding Training Handbook: Terminology Andclassifications Delivery Service
Training Handbook
2018-19
Terminology andClassifications Delivery Service
Contents
1 Introduction 3
1.1 Purpose of document 3
1.1.1 Audience 3
1.1.2 Background 4
1 Introduction
Guidance associated with Data Security and Protection Toolkit Standard 3 (former
Information Governance Toolkit Requirement 510) confirms that an organisation must
ensure that all its clinical coders are sufficiently trained so that they maintain the highest
standards of clinical coding. Training programmes for clinical coding staff entering coded
clinical data must be comprehensive and use material that conforms to national clinical
coding standards. The guidance further describes that novice clinical coders undertake
formal Clinical Coding Standards Course classroom training within six months of
commencing employment and that they attend Clinical Coding Standards Refresher Course
training every three years thereafter. It also describes that the organisation should provide a
training and assessment framework which supports its clinical coders in gaining Accredited
Clinical Coder (ACC) status by passing the National Clinical Coding Qualification (UK)
(NCCQ UK).
The contents of the national clinical coding training programmes provide the necessary
training in the general and specialist knowledge and skills required to use the national clinical
coding standards for the following classifications used in everyday clinical coding within the
NHS:
• ICD-10: International statistical classification of disease and related health problems –
Fifth Edition (2016)
• OPCS-4: OPCS Classification of Interventions and Procedures Version 4.8 (April
2017).
The success of the training delivered depends upon the commitment and competence of the
individual and clear support from their clinical coding manager. It is therefore essential that
an individual and their organisation understand the base knowledge and skills required as
well as the ongoing commitment.
This Handbook provides the activities, roles and protocols which individually and collectively
ensure that standards associated with national clinical coding training are met.
Experienced and accredited clinical coders needing to refresh and further develop their
existing skills and knowledge to apply national clinical coding standards for the ICD-10 and
OPCS-4 classifications.
Clinical coders who will be sitting the NCCQ (UK) examination who need to:
• understand the requirements and the framework for passing the exam
• refresh their skills and knowledge in applying national clinical coding standards for the
ICD-10 and OPCS-4 classifications
• gain a basic understanding of the uses, benefits and structure of SNOMED CT and
the differences between a Classification and a Nomenclature
• increase their knowledge of coding audit and wider coding areas on which the
questions in the miscellaneous section of the paper are based.
Line managers to understand the level of ongoing commitment required by the individual, the
line manager and the organisation to ensure support for staff seeking to become accredited
clinical coders in the department to ensure robust data quality.
1.1.2 Background
Accurate and comprehensive coded clinical data is essential for reliable and effective clinical
and statistical analysis. A regular internal programme of clinical coding training ensures the
quality of coded clinical data to satisfy NHS regulatory bodies that organisations exemplify
best practice and promote a culture of continuous improvement.
The national clinical coding training courses/programmes support organisations by ensuring
the availability of the necessary training to promote highly qualified and skilled staff. The
CCSC, CCSRC and NCCQ (UK) Revision Programme materials are developed and
maintained by the Terminology and Classifications Delivery Service – the authoritative
source of clinical classifications (ICD-10 and OPCS-4) and coding standards that underpin
the health, public health and social care systems by providing quality information to support
evidence-led care to patients and populations.
The content and format of the CCSC, CCSRC and NCCQ (UK) Revision Programme
materials are developed in collaboration with approved clinical coding trainers through the
Clinical Coding Trainer Sub-Groups.
It is essential therefore, that applicants fulfil all of the following criteria prior to attending the
CCSC:
1. Have been employed as a clinical coder for between one-six months. Ideally, the
novice clinical coder will have been working within the department for a minimum
of six weeks before attending the course
3. Have a structured training plan in place agreed with their line manager detailing
the time and resources available to complete all mandatory elements before,
during and after the course, as necessary
IMPORTANT INFORMATION:
Criteria 4 – Will be evidenced by provision of certificates.
Criteria 5 – The CCSC course trainer will email a Clinical Coding Reference Book/Manual
Download Confirmation Form template to the line manager before the course starts so that
the manager can confirm that their coder(s) has copies of all the necessary products for use
during the classroom-based course either in hard copy or electronic formats.
It is important that the applicant and Line Manager work together to ensure the
applicant meets all of the criteria listed above.
By the end of the Clinical Coding Standards Course, delegates will be able to:
• Select at least 18 out of 20 (90%) correct answers to the ICD-10 and OPCS-4 multiple
choice questions using their reference books
• Accurately complete a minimum of 38 out of 40 (95%) ICD-10 and OPCS-4 national
standard statements using the list of missing words provided
• Accurately assign ICD-10 5th Edition and OPCS-4 codes to at least 85% for the five
given case studies
• Complete all the required exercises in the Self-Learning Workbook within the
timeframes given by the course trainer.
Delegates and line managers need to be aware in advance of the course and module
objectives so that they understand the time and effort required to meet the objectives.
Delegates are required to:
Where Action Development Plan Agreements are required, the trainer, the delegate and the
delegate’s line manager must agree on the appropriate course of action, timeframes, how
the Action Plan will be checked and by whom.
The delegate will only receive a Certificate of Successful Completion when they fully
evidence they have met all the module and course objectives for the Clinical Coding
Standards Course. Certificates will therefore only be issued on successful completion of
Action Development Plans where these are required.
Ongoing requirements
• Mandatory Clinical Coding Standards Refresher Course training
• Specialty workshops
• Working towards accredited clinical coder (ACC) status.
Clinical coders must attend a Clinical Coding Standards Refresher Course once every 3
years from their successful completion of a Clinical Coding Standards Course.
It is essential therefore, that applicants fulfil all of the following criteria prior to attending the
CCSRC:
1. Have been employed as a clinical coder for 2-3 years before attending their first
CCSRC
2. Have attended a CCSRC three years ago (where applicable) (Provides previous
course certificate)
4. Have a structured training plan in place agreed with their line manager detailing
the time and resources available to complete all mandatory elements before,
during and after the course, as necessary
o Four Step Coding Process ICD-10 eLearning – all modules (Provides line
manager email confirmation / screen print from End of Course Assessment)
6. Have completed and returned the pre-course questionnaire within the timeframe
set by the trainer prior to the course start date to allow for adequate trainer
preparation
IMPORTANT INFORMATION:
Criteria 2 and 5 – Will be evidenced by provision of confirmation email / screen print /
certificate.
Criteria 6 – Will be evidenced by completion of the pre-course questionnaire.
Criteria 7 – Will be evidenced by line manager completion of the Clinical Coding Reference
Book/Manual Download Confirmation Form template to the Course Trainerbefore the course
starts so that the manager can confirm that their coder(s) has copies of all the necessary
products for use during the classroom-based course either in hard copy or electronic
formats.
It is important that the applicant and Line Manager work together to ensure the
applicant meets all of the criteria listed above.
Where Action Development Plan Agreements are required, the trainer, the delegate and the
delegate’s line manager must agree on the appropriate course of action, timeframes, how
the Action Plan will be checked and by whom.
The delegate will only receive a Certificate of Successful Completion when they fully
evidence they have met all the course objectives for the Clinical Coding Standards Refresher
Course. Certificates will therefore only be issued on successful completion of Action
Development Plans where these are required.
• Structure delegate revision time effectively using the recommended study guidelines
and the revision materials provided, in time to sit the National Clinical Coding
Qualification (UK).
• Assist the delegate to research broader issues connected to clinical coding including
uses of coded data, clinical coding audit, examples of ICD supplementary
classifications and several more.
• Assist the delegate to develop a basic understanding of SNOMED CT.
• Allow the delegate to discuss areas of uncertainty with the programme trainer(s) and
fellow delegates.
• Assess delegate current knowledge of national coding standards, anatomy and
physiology and medical terminology and identify any areas of weakness by sitting a
mock exam(s) under examination conditions.
NCCQ (UK) Revision Programme training can be arranged/booked through one of the
following options:
1. An in-house Terminology and Classifications Delivery Service approved Experienced
clinical coding trainer within your own department
2. A Terminology and Classifications Delivery Service approved Experienced clinical
coding trainer based within a neighbouring / other Trust
3. A Terminology and Classifications Delivery Service approved Experienced clinical
coding trainer based within a Clinical Coding Academy (under the Education, Training
and Audit section) if you are a subscribing Trust
4. A Commercial / Independent Terminology and Classifications Delivery Service
approved experienced clinical coding trainer.
NB: A list of approved clinical coding trainers who have given us their permission to publish
their details is available using the search facility on Delen.
Confirmation of a trainer’s ‘approved’ status for those trainers whose names do not appear
on the list can be obtained by emailing [email protected].
Training programme costs will vary depending on the chosen option and fees are available
directly from the training provider, and not the Terminology and Classifications Delivery
Service.
Refer to the NCCQ (UK) Revision Programme details (Section 4.3) for further information
about pre-programme, programme and post-programme requirements.
With the exception of re-sit candidates, all applicants must attend all three Modules which
cover the following content:
Module 1 (One-two days in length to be delivered 5 months before the exam date):
Pre Exam Study Day 1
• Discussions / responses to questions about the
o Study Guide
o Bibliography
o Syllabus
• Issue the Self-Learning Workbook on Miscellaneous issues
• SNOMED CT
• Index Trailing / Data Extraction
• Consolidate the learning around
o A&P and Medical Terminology
o Organisation and Structure of ICD-10 and OPCS-4
o Four Step Coding Process
• Issue the NCCQ (UK) Programme Revision Workbook and Answer Book
• Confirm availability of the ICD-10 and OPCS-4 Exercise Booklets
Day 2 p.m.
• ICD-10 KLPs
o Presentations (additional chapters)
o Activities and Exercises
Day 3 a.m.
• OPCS-4 KLPs
o Presentations (additional chapters)
o Activities and Exercises
Day 3 p.m.
• Clarification of Grey Areas
• Exam style questions/discussions
• Activities and Exercises
• Discussion Case Studies
• Assign ICD-10 and OPCS-4 codes to the questions in the Practical Mock Exam to at
least 90% accuracy.
• Complete SNOMED CT, Anatomy and Physiology, Medical Terminology and ICD-10
and OPCS-4 theory questions in the Theory Mock Exam to at least 60% accuracy.
• Correctly write down the answers to all 10 of the given questions about the
Examination Day.
Delegates and line managers need to be aware in advance of the Programme that
ongoing personal study is required in-between modules using the workbooks provided.
This includes completion of the self-learning workbook using the website links provided
before undertaking Module 2. This will prepare the delegate to answer questions in the
Miscellaneous Issues section in Module 2 of the NCCQ (UK) Revision Programme and in
Paper 2 of the actual National Clinical Coding Qualification (UK).
The delegate will receive a Certificate of Successful Completion when they fully evidence
they have met all the objectives for the NCCQ (UK) Revision Programme. NB:
Certificates of Completion will be issued on a modular basis to those delegates only
sitting certain modules, e.g. re-sit candidates.
4.3.1.6 What will the course cover?
Reinforcement of the importance of self-directed study
• Using the National Clinical Coding Qualification (UK) syllabus, framework and
bibliography and self-directed learning documents to populate a structured individual
study plan
Reinforcement of the four step coding process
• Using each step of the Four Step Coding Process to correctly assign ICD-10 and
OPCS-4 codes
• Using the four step coding process to complete full index trails
Reinforcement of the organisation and structure of the classifications
• Completing short and longer style examination questions about the organisation and
structure of ICD-10 and OPCS-4
Applying national clinical coding standards
• Completing quick fire and case study scenarios in the exercises provided and in the
ICD-10 and OPCS-4 Exercise Booklets (and Answer Booklets) available on request
from [email protected]
Maintaining data extraction skills
• Selecting all relevant conditions, circumstances and interventions to be coded in case
studies by following national clinical coding standards
Monitoring and assessment
• Completing mock examination(s)
• Identifying areas for further revision where necessary
Time management
• Completing elements of the individual study plan to stated timeframes
Study itself is expected to require a total of 30-35 hours. The course must be completed
within a maximum of four months, but it is possible to complete it within as little as a week.
Registration is required.
https://www.snomed.org/snomed-ct/learn-more/snomed-ct-foundation-course-applications
The content of these demonstrations is for training purposes only and therefore may not
match the current content of the NHS Data Model and Dictionary.
http://www.datadictionary.nhs.uk/web_site_content/pages/help_pages/demonstrations.asp?s
hownav=0