0% found this document useful (0 votes)
2K views28 pages

National Clinical Coding Training Handbook: Terminology Andclassifications Delivery Service

Uploaded by

anton_susanto10
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
2K views28 pages

National Clinical Coding Training Handbook: Terminology Andclassifications Delivery Service

Uploaded by

anton_susanto10
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 28

National Clinical Coding

Training Handbook
2018-19
Terminology andClassifications Delivery Service

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.
National Clinical Coding Training Handbook 2018-19

Contents
1 Introduction 3
1.1 Purpose of document 3
1.1.1 Audience 3
1.1.2 Background 4

2 Clinical Coding Standards Course 4


2.1 Pre-requisite skills, knowledge and experience 4
2.2 Booking a place on the Clinical Coding Standards Course (CCSC) 5
2.3 Clinical Coding Standards Course Details 6
2.3.1 Course Overview 6

3 Clinical Coding Standards Refresher Course 12


3.1 Pre-requisite skills, knowledge and experience 12
3.2 Booking a place on the Clinical Coding Standards Refresher Course (CCSRC) 13
3.3 Clinical Coding Standards Refresher Course Details 14
3.3.1 Course Overview 14

4 NCCQ (UK) Revision Programme 18


4.1 Pre-requisite skills, knowledge and experience 19
4.1.1 Mandatory Pre-requisites 19
4.1.2 Desirable Pre-requisites 19
4.2 Booking a place on the NCCQ (UK) Revision Programme 20
4.3 NCCQ (UK) Revision Programme Details 21
4.3.1. Programme Overview 21

5 Other Useful Information 27


5.1 The Health Informatics Career Framework (HICF) 27
5.2 Informed: An introduction to the use of informatics in healthcare 28
5.3 SNOMED CT Foundation Course 28
5.4 Introduction to SNOMED CT Webinars 28
5.5 NHS Data Dictionary eLearning 28

Copyright © 2018 Health and Social Care Information Centre. 2


National Clinical Coding Training Handbook 2018-19

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.

1.1 Purpose of document


The document provides an outline for the mandatory national Clinical Coding Standards
Course (CCSC), Clinical Coding Standards Refresher Course (CCSRC) and the NCCQ (UK)
Revision Programme so that for each course/programme the reader has a thorough
understanding of:
• Pre-requisite skills, knowledge and experience
• Content and format (pre-course, course, post-course)
• Benefits of national clinical coding training
• Delegate and line manager roles and responsibilities
• Ongoing requirements and Continued Professional Development (CPD) to maintain
clinical coding skills and work towards accredited clinical coder (ACC) status.
1.1.1 Audience
Novice clinical coders recently employed in coding departments who need to develop the
required skills and knowledge to apply national clinical coding standards for the ICD-10 and
OPCS-4 classifications.

Copyright © 2018 Health and Social Care Information Centre. 3


National Clinical Coding Training Handbook 2018-19

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.

2 Clinical Coding Standards Course


2.1 Pre-requisite skills, knowledge and experience
The Clinical Coding Standards Course (CCSC) pre-requisite criteria ensure that an applicant
has the base skills and knowledge required to become a clinical coder.
The CCSC is open to all staff already employed as a novice clinical coder in an NHS Trust
(including a Mental Health Trust, although there is a separate dedicated Mental Health
Standards Course outside the scope of this document as it is developed and maintained by
the Clinical Coding Academy Network) or an independent sector treatment centre (ISTC)
which treats and codes consultant episodes for NHS patients.

It is essential therefore, that applicants fulfil all of the following criteria prior to attending the
CCSC:

Copyright © 2018 Health and Social Care Information Centre. 4


National Clinical Coding Training Handbook 2018-19

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

2. Have a personal commitment to continued professional development including


completion of assessment based learning in a variety of formats, e.g. classroom-
led learning, eLearning, self-learning and webinars

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

4. Have completed the following two mandatory eLearning courses prior to


attendance on the classroom CCSC

o Basic Anatomy and Physiology eLearning – all modules (Provides certificate /


screen print from End of Course Assessment)
o Basic Introduction to Clinical Coding – Modules 1 and 2 (Provides certificate /
screen print from End of Module Tests).

5. Have all the necessary classification books, reference books/manuals,


Chemotherapy Regimen and High Cost Drugs Lists and associated Clinical
Coding Guidance documentation to bring with them to the classroom course
either in hard copy or electronic formats.

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.

2.2 Booking a place on the Clinical Coding Standards


Course (CCSC)
As per guidance associated with Data Security and Protection Toolkit Standard 3 (formerly
covered by Information Governance Toolkit Requirement 510), coding managers must
ensure that their novice clinical coder is booked on to a classroom-based CCSC within six
months of commencing employment within their department.
CCSC training can be arranged/booked through one of the following options:
1. An in-house Terminology and Classifications Delivery Service approved Apprentice or
Experienced clinical coding trainer within your own department

Copyright © 2018 Health and Social Care Information Centre. 5


National Clinical Coding Training Handbook 2018-19

2. A Terminology and Classifications Delivery Service approved Apprentice or


Experienced clinical coding trainer based within a neighbouring / other Trust
3. A Terminology and Classifications Delivery Service approved Apprentice or
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 Apprentice or Experienced clinical coding trainer.
NB: A list of approved clinical coding trainers who have given their permission for us to
publish their details is available using the search facility on Delen at
https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=355716&exp=e1
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 CCSC course details (Section 2.3) for further information about pre-course,
course and post-course requirements.

2.3 Clinical Coding Standards Course Details


Course delegates and their line managers need to be aware of all the following content prior
to booking on to a course.
2.3.1 Course Overview
2.3.1.1 Mandatory pre-course eLearning
As referenced in Section 2.1, delegates must complete the following two mandatory
eLearning courses accessible via Delen before attending the classroom element of the
CCSC:
o Basic Anatomy and Physiology eLearning – all modules
o Basic Introduction to Clinical Coding – Modules 1 and 2
There are 11 modules within the Basic Anatomy and Physiology eLearning package that the
novice coder must complete, including all the end of module and overall assessments.
Estimated time to complete this package is approximately 5 hours. A copy of the delegate’s
overall assessment results must be made available to the CCSC trainer prior to attending the
classroom course. The delegate and their line manager must therefore factor in enough
time before the classroom course for this to be done.
There are two modules within the ‘Basic Introduction to Clinical Coding’ eLearning package,
both of which require the delegate to complete a Workbook requiring sign-off by their line
manager. Each Workbook contains a number of activities. Some activities are to be done at
the delegate’s desk using the internet and other resources; some they need to find out
information from within their organisation. The Workbooks must be complete and taken with
the delegate to the first day of their Clinical Coding Standards Course; their trainer will ask to
see these. A copy of the delegate’s test results from each module must be made available to
the CCSC trainer prior to attending the classroom course. The delegate and their line
manager must therefore factor in enough time before the classroom course for this to
be done.

Copyright © 2018 Health and Social Care Information Centre. 6


National Clinical Coding Training Handbook 2018-19

2.3.1.2 Course modules


This practical assessment-based course teaches recently appointed novice clinical coders
how to use their classification books and follow the four step coding process to ensure
correct application of ICD-10 and OPCS-4 national clinical coding standards and facilitate
accurate coded clinical data.
This course is delivered across four modules in no less than 21 days and no more than 25
days. The exact course length must be agreed in advance between the Approved Clinical
Coding Trainer and the delegate’s line manager depending on the needs of the delegate /
organisation.
The four modules cover:
Module 1: Organisation and structure of ICD-10 and OPCS-4
Four Step Coding Process for ICD-10 and OPCS-4
Essential Coding Pointers
Several ICD-10 and OPCS-4 coding standards (general, chapter and coding)
Self-Learning Workbook Exercises
Recap Exercise
Post Module written Assessment (practical and theory papers)
Module 2: Several ICD-10 and OPCS-4 coding standards (general, chapter and coding)
Case Studies
Self-Learning Workbook Exercises
Recap Exercise
Post Module written Assessment (practical and theory sections)
Module 3: Several ICD-10 and OPCS-4 coding standards (general, chapter and coding)
Case Studies
Self-Learning Workbook Exercises
Recap Exercise
Post Module written Assessment (practical and theory sections)
Module 4: Several ICD-10 and OPCS-4 coding standards (general, chapter and coding)
Case Studies
Self-Learning Workbook Exercises
Recap Exercise
Data Extraction
Post Module written Assessment (practical and theory sections)
End of Course Assessment
The content of Modules 2 and 3 and the ICD-10 and OPCS-4 chapter element of Module 4
can be delivered in any order. The timing of the modules is open for discussion between the
course trainer and the coding manager, e.g. one module each month for four consecutive

Copyright © 2018 Health and Social Care Information Centre. 7


National Clinical Coding Training Handbook 2018-19

months, four modules delivered over eight weeks with a


week’s gap in-between modules, etc.
“The course was both
informative and enjoyable -
2.3.1.3 Benefits to the delegate I really enjoyed the way it
• Provides an optimal learning environment was taught through
presentations and lots of
• Gives access to highly experienced and skilled interactive exercises both
Terminology and Classifications Delivery Service requiring me to work as an
Approved Clinical Coding Trainers individual and with course
• Provides understanding of the correct application of mates. There were lots of
the national clinical coding training standards for both opportunities to ask
questions and I found the
ICD-10 and OPCS-4
examples that we were
• Develops delegate confidence to accurately code coding to be really clear
when back in the workplace, through practical and helpful to real-life
activities and assessments throughout the course problems in case notes.”
• Gives a greater understanding of the role and
importance of clinical coding within the delegate’s
working environment
• Supports an ongoing record of continued
professional development through regular ongoing
training
• Can provide an opportunity to network with clinical
coders from other organisations.

2.3.1.4 Benefits to the organisation


• Elements of self-learning to instil research skills in the novice coder from the outset
• Set of rigorous objectives that delegates are assessed against to support
competence and confidence when back in the workplace
• Classroom delivery by a learner-focused Approved Clinical Coding Trainer who can
deliver formal clinical coding training that complies with the Clinical Coding Trainer
Framework and is engaging to all novice clinical coders
• Delivery by a skilled Approved Clinical Coding Trainer who understands the need for
accurate, high quality coded clinical data to support healthcare planning,
reimbursement, management of services, statistical analysis and research
• Increased effectiveness of formal training events and of learning transferred to the
workplace through ongoing online evaluation

• The opportunity to deliver a more cost-efficient in-house clinical coding training


programme to satisfy internal data quality, Data Security and Protection Toolkit
Standard 3 and other NHS regulatory body requirements.

2.3.1.5 Attendance criteria


This course is only available to clinical coders employed within an NHS Trust (including a
Mental Health Trust, although there is a separate dedicated Mental Health Standards Course
outside the scope of this document as it is developed and maintained by the Clinical Coding
Academy Network) or an independent sector treatment centre (ISTC) which treats and codes
consultant episodes for NHS patients.

Copyright © 2018 Health and Social Care Information Centre. 8


National Clinical Coding Training Handbook 2018-19

By the end of Module 1 delegates will be able to:


• Accurately assign ICD-10 5th Edition and OPCS-4 codes to at least 80% of questions
on the Post Module 1 Practical Assessment Paper
• Correctly write down the answers to at least 80% of the questions on the Post Module
1 Theory Assessment Paper.

By the end of Module 2 delegates will be able to:


• Accurately assign ICD-10 5th Edition and OPCS-4 codes to at least 85% of the
questions in the Practical section of the Post Module 2 Assessment Paper
• Correctly write down the answers to at least 85% of the questions in the Theory
section of the Post Module 2 Assessment Paper.

By the end of Module 3 delegates will be able to:


• Accurately assign ICD-10 5th Edition and OPCS-4 codes to at least 85% of the
questions in the Practical section of the Post Module 3 Assessment Paper
• Correctly write down the answers to at least 85% of the questions in the Theory
section of the Post Module 3 Assessment Paper.

By the end of Module 4 delegates will be able to:


• Accurately assign ICD-10 5th Edition and OPCS-4 codes to at least 85% of the
questions in the Practical section of the Post Module 4 Assessment Paper
• Correctly write down the answers to at least 85% of the questions in the Theory
section of the Post Module 4 Assessment Paper.

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:

• Complete a number of exercises in their Self-Learning Workbook throughout the


course and in-between modules
• Successfully complete written theory and practical assessments at the end of each
module and an overall course assessment
• Successfully complete any Interim Attendance Action Development Plans when a
delegate is unable to attend any part (i.e. session, day or module) of the course for
whatever reason(s)
• Successfully complete any Action Development Plan Agreements within agreed
timescales where an individual does not meet any of the module and/or course
objectives.

Copyright © 2018 Health and Social Care Information Centre. 9


National Clinical Coding Training Handbook 2018-19

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.

2.3.1.6 What will the course cover?


Using classification books and reference products
• Learning about the organisation and structure of ICD-10 Volumes 1, 2 and 3
• Learning about the organisation and structure of OPCS-4 Volumes I and II
• Using each step of the Four Step Coding Process to correctly assign ICD-10 and
OPCS-4 codes
• Navigating the National Clinical Coding Standards ICD-10 5th Edition and OPCS-4
reference books to locate national clinical coding standards
• Using the Coding Clinic
• Understanding the structure and content of the OPCS-4 Chemotherapy Regimens
and High Cost Drugs Lists
• Learning how to use the Chemotherapy Regimens Clinical Coding Standards and
Guidance OPCS-4 document
• Learning how to use the High Cost Drugs Clinical Coding Standards OPCS-4
document.
Applying national clinical coding standards
• Completing quick-fire scenarios and more detailed case studies to correctly assign
ICD-10 and OPCS-4 codes for all ICD-10 and OPCS-4 chapters
• Completing recap exercises and other activities to reinforce the practical and
theoretical aspects of national clinical coding standards for ICD-10 and OPCS-4
• Using all available reference products to support accurate code assignment.
Data extraction and research
• Undertaking basic internet searches to research various illnesses and interventions
• Selecting all relevant conditions, circumstances and interventions to be coded by
following basic data extraction guidance and reviewing sample source documentation.
Monitoring and assessment
• Completing regular practical and theoretical assessments to monitor personal
progress
• Identifying areas for further development where necessary.
Time management
• Completing self-learning, individual exercises, assessments, action plans (where
required), and group activities to required deadlines.

Ongoing requirements
• Mandatory Clinical Coding Standards Refresher Course training
• Specialty workshops
• Working towards accredited clinical coder (ACC) status.

Copyright © 2018 Health and Social Care Information Centre. 10


National Clinical Coding Training Handbook 2018-19

2.3.1.7 Course Materials


Each delegate receives:
• Delegate course folder
• Written Exercises and Answer sheets
• Reference Handouts
• ICD-10 and OPCS-4 Exercise and Answer Booklets
• Self-Learning Workbook Template
• Individual Course Record of Assessment / performance report
• Certificate of Successful Completion.

2.3.1.8 Reference Materials


Important information
The delegate’s line manager must supply their delegate with a copy of the following in either
hard copy or electronic format for use during the course:
• Volumes 1 and 3 of ICD-10 5th Edition (fully updated to reflect the errata published in
the Coding Clinic Ref 112)*
• OPCS-4.8 Volumes I and II*
• National Clinical Coding Standards ICD-10 5th Edition reference book (2018)**
• National Clinical Coding Standards OPCS-4 reference book (2018)**
• Basic Anatomy and Physiology Instruction Manual**
• Supplementary Information Booklet OPCS-4.8**
• National Tariff Chemotherapy Regimens List**
• National Tariff High Cost Drug List**
• Chemotherapy Regimens Clinical Coding Standards and Guidance OPCS-4**
• High Cost Drugs Clinical Coding Standards OPCS-4**
NB: All classification books highlighted with an * should preferably be new and not passed
down from previous users as this can cause confusion for novice coders. ICD-10 5th Edition
books can be purchased from The Stationery Office via
https://www.tsoshop.co.uk/bookstore.asp?FO=1160643&DI=643306
To order OPCS-4.8 books, follow the link on Delen at
https://hscic.kahootz.com/connect.ti/t_c_home/view?objectId=297875#297875
NB: Delegates are welcome to bring laptops/tablets to access electronic versions of the
products highlighted with an **. These can be found on the Key Publications page on Delen
Delegates may also use the OPCS-4.8 e-Version and ICD-10 5th Edition e-Version*. These
products can be downloaded via Delen:
Coding Clinic Ref 88: Coding of Co-morbidities
NB: Delegates can download the latest version of the Coding Clinic onto their laptops/tablets
if desired from Delen.

2.3.1.9 Course Timings


The course timings will be provided by the course trainer.

2.3.1.10 Delegate Responsibilities – Summary


The delegate is responsible for:

Copyright © 2018 Health and Social Care Information Centre. 11


National Clinical Coding Training Handbook 2018-19

• Ensuring punctuality at all time


• Respecting the course trainer and fellow delegates
• Attending all modules of the Clinical Coding Standards Course
• Completing and evidencing all mandatory pre-course eLearning prior to the classroom
training
• Completing all Self-Learning Workbook exercises during the course to the timeframes
instructed by the course trainer
• Completing all assessments to the required criteria
• Completing all necessary Action Development Plans to the required criteria and
timeframes supplied by the course trainer.

2.3.1.11 Line Manager Responsibilities – Summary


The line manager is responsible for:
• Ensuring their novice coder completes a CCSC within six months of employment
• Providing clean copies of all reference products described in Section 2.3.1.8 above
• Providing ongoing support to the delegate to ensure sufficient time and resources are
available for completion of the two mandatory eLearning packages before the
classroom course, all modules of the course including time to complete Self-Learning
exercises in-between modules
• Discussing with the course trainer appropriate Action Development Plan Agreements
and timeframes during the course and/or after the course where necessary, and
providing ongoing support for the delegate to complete these.

2.3.1.12 Next Steps


Successful completion will result in compliance with Data Security and Protection Toolkit
Standard 3.

3 Clinical Coding Standards Refresher Course


3.1 Pre-requisite skills, knowledge and experience
The Clinical Coding Standards Refresher Course pre-requisite criteria ensure that an
applicant has the ongoing skills and knowledge required by a clinical coder.
The CCSRC is open to all staff already employed as a clinical coder in an NHS Trust
(including a Mental Health Trust, although there is a separate dedicated Mental Health
Standards Refresher Course outside the scope of this document as it is developed and
maintained by the Clinical Coding Academy Network) or an independent sector treatment
centre (ISTC) which treats and codes consultant episodes for NHS patients.

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

Copyright © 2018 Health and Social Care Information Centre. 12


National Clinical Coding Training Handbook 2018-19

2. Have attended a CCSRC three years ago (where applicable) (Provides previous
course certificate)

3. Have a personal commitment to continued professional development including


completion of assessment based learning in a variety of formats, e.g. classroom-
led learning, eLearning, self-learning, webinars

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

5. Have completed the following mandatory eLearning course prior to attendance on


the classroom CCSRC:

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

7. Have all the necessary classification books, reference books/manuals,


Chemotherapy Regimen and High Cost Drugs Lists and associated Clinical
Coding Guidance documentation to bring with them to the classroom course
either in hard copy or electronic formats.

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.

3.2 Booking a place on the Clinical Coding Standards


Refresher Course (CCSRC)
As per guidance associated with Data Security and Protection Toolkit Standard 3, coding
managers must ensure that their clinical coder attends CCSRC training every 3 years.
CCSRC training can be arranged/booked through one of the following options:

Copyright © 2018 Health and Social Care Information Centre. 13


National Clinical Coding Training Handbook 2018-19

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 Teminology 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 their permission for us 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 course 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 CCSRC course details (Section 3.3) for further information about pre-
course, course and post-course requirements.

3.3 Clinical Coding Standards Refresher Course Details


Course delegates and their line managers need to be aware of all the following content prior
to booking on to a course.
3.3.1 Course Overview
This practical assessment-based course is fundamental to the continued professional
development of all experienced clinical coders by assessing that they are keeping their
practical coding skills and theoretical knowledge up-to-date for the ICD-10 and OPCS-4
clinical classifications and associated updates. The course also provides experienced clinical
coders with the opportunity to reinforce the four step coding process to ensure correct
application of ICD-10 and OPCS-4 national clinical coding standards to facilitate accurate
coded clinical data.
This course is delivered across four days in a classroom environment.
3.3.1.1 Mandatory pre-course eLearning and questionnaire
As referenced in Section 3.1, delegates must complete the following mandatory eLearning
course accessible via Delen before attending the classroom element of the CCSRC:
o Four Step Coding Process ICD-10 eLearning – all 7 modules
Estimated time to complete this package is approximately 1.5 hours. The delegate and their
line manager must therefore factor in enough time before the classroom course for
this to be done.
Prior to the course starting, the course trainer will email the CCSRC pre-course
questionnaire which must be completed by the delegate and returned to the course trainer
within the given timeframe to allow for adequate trainer preparation. This will help ensure the
course meets both the needs of the delegates and the organisation. The Trainer will aim to
cover any areas of concern/problems time permitting; however this is not the correct forum
for discussing individual clinical coding queries. These must be submitted using the National
Clinical Coding Query Mechanism explained on Delen.

Copyright © 2018 Health and Social Care Information Centre. 14


National Clinical Coding Training Handbook 2018-19

3.3.1.2 Benefits to the delegate


• Provides an optimal learning environment

• Gives access to highly experienced and skilled “Given the frequency of


Terminology and Classifications Delivery Service clinical coding standard
Approved Clinical Coding Trainers amendments I found this
course to be a fantastic
• Provides reinforcement of the correct application of the reinforcement of my
national clinical coding training standards for both ICD- previous knowledge and it
10 and OPCS-4 also filled in a few gaps
where guidance had been
• Opportunity to refresh and consolidate existing practical
updated. I would certainly
coding skills for ICD-10 and OPCS-4 recommend this course to
• Opportunity to refresh and consolidate existing my colleagues not only
theoretical coding knowledge for ICD-10 and OPCS-4 because of it being
compulsory but also as it
• Opportunity to apply this knowledge to consistently and helps to keep your work up
accurately identify the correct ICD-10 and OPCS-4 to date with the latest
codes for a range of typical case note and more standards.”
complex scenarios
• Opportunity to share clinical coding experiences and
best practice with fellow delegates
• Opportunity to refresh and consolidate existing medical
terminology and anatomy and physiology knowledge “The course was fantastic,
• Identifies any areas for further development it covered all areas that I
felt I needed to work on. I
• Increases delegate confidence to accurately code when strongly recommend it to
back in the workplace, through practical activities, group other coders.”
discussions and assessments throughout the course
• Supports an ongoing record of continued professional
development through regular ongoing training
• Can provide an opportunity to network with
experienced clinical coders from other organisations.

3.3.1.3 Benefits to the organisation


• Set of rigorous objectives that delegates are assessed against to support ongoing
competence and confidence when back in the workplace
• A blended learning approach to reinforcing national clinical coding standards
• Classroom delivery by a learner-focused Approved Clinical Coding Trainer who can
deliver formal clinical coding training that complies with the Clinical Coding Trainer
Framework and is engaging to all experienced clinical coders
• Delivery by a skilled Approved Clinical Coding Trainer who understands the need for
accurate, high quality coded clinical data to support healthcare planning,
reimbursement, management of services, statistical analysis and research
• Increased effectiveness of formal training events and of learning transferred to the
workplace through ongoing online evaluation

Copyright © 2018 Health and Social Care Information Centre. 15


National Clinical Coding Training Handbook 2018-19

• The opportunity to deliver a more cost-efficient in-house clinical coding training


programme to satisfy internal data quality, Data Security and Protection Toolkit
Standard 3 and other NHS regulatory body requirements.

3.3.1.4 Attendance criteria


This course is only available to experienced clinical coders employed within an NHS Trust
(including a Mental Health Trust, although there is a separate dedicated Mental Health
Standards Refresher Course outside the scope of this document as it is developed and
maintained by the Clinical Coding Academy Network) or an independent sector treatment
centre (ISTC) which treats and codes consultant episodes for NHS patients.

By the end of the course delegates will be able to:


• Accurately assign ICD-10 and OPCS-4 codes to the given case studies using the
Four Step Coding Process.
• Correctly match the metastatic cancer statements to the examples in the given card
activity.
• Correctly assign the OPCS-4 codes to the Osteotomy activity using the osteotomy
table provided.
• Select the correct option for at least 17 of the 20 given multiple choice questions,
using their reference books.
• Correctly assign ICD-10 and OPCS-4 codes to at least 85% accuracy for six case
studies.
Delegates and line managers need to be aware in advance of the course objectives so that
they understand the time and effort required to meet the objectives. Delegates are required
to:

• Complete a number of exercises throughout the course


• Successfully complete written theory and practical assessments at the end of the
course. NB: The practical assessment involves completion of 4 mandatory case
studies and then two further case studies from a choice of six
• Successfully complete any Interim Attendance Action Development Plans when a
delegate is unable to attend any part (i.e. session or day) of the course for whatever
reason(s)
• Successfully complete any Action Development Plan Agreements within agreed
timescales where an individual does not meet any of the course objectives.

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.

3.3.1.5 What will the course cover?


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

Copyright © 2018 Health and Social Care Information Centre. 16


National Clinical Coding Training Handbook 2018-19

Applying national clinical coding standards


• Completing quick-fire scenarios and more detailed case studies to correctly assign
ICD-10 and OPCS-4 codes
• Completing other individual and group activities to reinforce the practical and
theoretical aspects of national clinical coding standards for ICD-10 and OPCS-4
• Using all available reference products to support accurate code assignment
Maintaining data extraction skills
• Selecting all relevant conditions, circumstances and interventions to be coded in
realistic case studies by following general coding standards
Monitoring and assessment
• Completing practical and theoretical end of course assessments to monitor personal
progress
• Identifying areas for further development where necessary
Time management
• Completing individual exercises, assessments, action plans (where required), and
group activities to required deadlines
Ongoing requirements
• Mandatory three-yearly Clinical Coding Standards Refresher Course training
• Specialty workshops
• Accredited clinical coder status (where still required)

3.3.1.6 Course Materials


Each delegate receives:
• Delegate course folder
• Participant’s Workbook and Answer Book
• Reference Handouts
• Individual Course Record of Assessment / performance report
• Certificate of Successful Completion.

3.3.1.7 Reference Materials


The delegate’s line manager must ensure their delegate has a copy (either hard copy or
electronic format) of the following for use during the course:
• Volumes 1 and 3 of ICD-10 5th Edition (fully updated to reflect the errata published in
the Coding Clinic Ref 112)
• OPCS-4.8 Volumes I and II
• National Clinical Coding Standards ICD-10 5th Edition reference book (2018)*
• National Clinical Coding Standards OPCS-4 reference book (2018)*
• National Tariff Chemotherapy Regimens List*
• National Tariff High Cost Drug List*
• Chemotherapy Regimens Clinical Coding Standards and Guidance OPCS-4*
• High Cost Drugs Clinical Coding Standards OPCS-4*
NB: Delegates are welcome to bring laptops/tablets to access electronic versions of the
products highlighted with an *. These can be found on the Key Publications page on Delen.
Delegates may also use the OPCS-4.8 e-Version and ICD-10 e-Version*. These products
can also be downloaded via Delen:

Copyright © 2018 Health and Social Care Information Centre. 17


National Clinical Coding Training Handbook 2018-19

Coding Clinic Ref 88: Coding of Co-morbidities


NB: Delegates can download the latest version of the Coding Clinic onto their laptops/tablets
if desired. This can be found on the Key Publications page on Delen.
3.3.1.8 Course Timings
The course timings are:
Day 1: 09.00 – 16.45
Day 2: 09.00 – 16.45
Day 3: 09.00 – 16.45
Day 4: 09.00 – 15.45

3.3.1.9 Delegate Responsibilities – Summary


The delegate is responsible for:
• Ensuring punctuality at all time
• Respecting the course trainer and fellow delegates
• Attending all days of the Clinical Coding Standards Refresher Course
• Completing and evidencing all mandatory pre-course eLearning prior to the classroom
training
• Completing all assessments to the required criteria
• Completing all necessary Action Development Plans to the required criteria and
timeframes supplied by the course trainer.

3.3.1.10 Line Manager Responsibilities – Summary


The line manager is responsible for:
• Ensuring their clinical coder completes a CCSRC every 3 years
• Ensuring availability of all reference products described in Section 3.3.1.7 above
• Providing ongoing support to the delegate to ensure sufficient time and resources are
available for completion of the mandatory eLearning package before the classroom
course
• Discussing with the course trainer appropriate Action Development Plan Agreements
and timeframes during the course and/or after the course where necessary, and
providing ongoing support for the delegate to complete these.

3.3.1.11 Next Steps


Successful completion will result in compliance with Data Security and Protection Toolkit
Standard 3.

4 NCCQ (UK) Revision Programme


This Programme has a modular format (Modules 1, 2 and 3) delivered in a minimum of four
days over a six month period. Its content and format have been designed to better support
candidates studying for the National Clinical Coding Qualification (UK). The Programme
aims to:

Copyright © 2018 Health and Social Care Information Centre. 18


National Clinical Coding Training Handbook 2018-19

• 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.

4.1 Pre-requisite skills, knowledge and experience


In order to achieve the high level of attainment required for the qualification, a clinical coder
must typically have undertaken a 2-3 year development plan with their employer to complete
the required national standard clinical coding training, acquire the breadth of skills,
knowledge and practical work experience to become competent in clinical coding and be
ready to sit the examination papers.
As part of this development plan a clinical coder will need to complete the national Clinical
Coding Standards Course (CCSC) and preferably the national Clinical Coding Standards
Refresher Course (CCSRC) before attending the NCCQ (UK) Revision Programme.
This Programme is also open to coders needing to re-sit Paper 1, Paper 2, or both papers of
the National Clinical Coding Qualification (UK).
4.1.1 Mandatory Pre-requisites
Before attending the NCCQ (UK) Revision Programme, attendees must have read the
following documents/or attended the stated course. All documents are available on the
National Clinical Coding Qualification (UK) page on Delen.
Mandatory Pre-requisite
NCCQ (UK) 2018-19 Syllabus, Framework, Bibliography
NCCQ (UK) Self-directed Learning Framework 2018-19
NCCQ (UK) September 2017 Revision Aid
Clinical Coding Standards Course (21-25 days)

4.1.2 Desirable Pre-requisites


The following activities are advisable to complete before attending the NCCQ (UK) Revision
Programme as they will give the attendee a better understanding of the contents covered by
the Approved Clinical Coding Trainer(s) delivering the classroom modules.
Desirable Pre-requisite
SNOMED CT Education and Training including: Introduction to

Copyright © 2018 Health and Social Care Information Centre. 19


National Clinical Coding Training Handbook 2018-19

SNOMED CT Webinar (Not the General Practice webinars)*


SNOMED CT eLearning
Reviewed the SNOMED CT Brochure
SNOMED CT and Clinical Coding Presentation
Four Step Coding Process ICD-10 elearning module**
Basic Introduction to Clinical Coding elearning module**
Anatomy and Physiology elearning module**
Clinical Coding Standards Refresher Course
Speciality Clinical Coding Workshops

* Please see https://digital.nhs.uk/article/762/SNOMED-CT-webinars for dates of Introduction


to SNOMED CT webinars.
** Accessible via Delen
In addition applicants must have:
1. A personal commitment to continued professional development and study including
completion of a number of activities in a variety of formats, e.g. classroom-led
revision, eLearning and self-learning / study.
2. The necessary classification books, reference books/manuals, Chemotherapy
Regimen and High Cost Drugs Lists and associated Clinical Coding Guidance
documentation to bring with them to the classroom course either in hard copy or
electronic formats.
IMPORTANT INFORMATION:
Mandatory Pre-requisite criteria – Will be evidenced by completion of the NCCQ (UK)
Revision Programme Pre-Information and Pre-Requisites form.
Desirable criteria – Will be evidenced where applicable by completion of the NCCQ (UK)
Revision Programme Pre-Information and Pre-Requisites form.
Criteria 2 – Will be evidenced by line manager completion of the Clinical Coding Reference
Book/Manual Download Confirmation Form template to the Programme trainer before the
Programme starts so that the manager can confirm that their coder(s) has copies of all the
necessary products for use during the classroom-based modules 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.

4.2 Booking a place on the NCCQ (UK) Revision


Programme
As per guidance associated with Data Security and Protection Toolkit Standard 3,
organisations 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).

Copyright © 2018 Health and Social Care Information Centre. 20


National Clinical Coding Training Handbook 2018-19

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.

4.3 NCCQ (UK) Revision Programme Details


Programme delegates and their line managers need to be aware of all the following content
prior to booking on to the Programme.
4.3.1. Programme Overview
This Programme is a modular programme designed primarily to support coders to pass the
National Clinical Coding Qualification (UK) through classroom-led revision and structured
revision workbooks to support ongoing self-directed study. It includes mock examination
papers that delegates sit under examination conditions.
This Programme is delivered in a minimum of four days across three separate modules.
Trainers can extend the length of this programme to suit the requirements of their delegates
and their employing organisations, for example, by extending Module 1 to two days,
incorporating delivery of a four day Clinical Coding Standards Refresher Course in-between
Modules 2 and 3.
4.3.1.1. Pre-Information and Mandatory Pre-Requisites
All delegates must complete the NCCQ (UK) Revision Programme Pre-Information and Pre-
Requisites form emailed to them by the programme trainer by the required deadline.
All line managers must complete the Clinical Coding Reference Book/Manual Download
Confirmation Form template and email back to the programme trainer before the programme
starts.
4.3.1.2 Programme Modules
This revision focused programme reinforces to delegates how to use their classification
books and the Four Step Coding Process to ensure correct application of ICD-10 and OPCS-
4 national clinical coding standards to help them pass the National Clinical Coding
Qualification (UK).

Copyright © 2018 Health and Social Care Information Centre. 21


National Clinical Coding Training Handbook 2018-19

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

Module 2 (Days 2 and 3 to be delivered 3 months before the exam date):


Day 2 a.m.
• Consolidate the learning in the form of exam style questions and discussions around:
o Miscellaneous Issues (Self-Learning workbook content)
o SNOMED CT
o A&P and Medical Terminology

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

Module 3 (Day 4 to be delivered 1 month before the exam date):


• Exam Techniques
• Exam paper layout and language used
• What is allowed to be written/annotated in both classifications
• What can be taken in to the examination room on the day
• Sit Mock Exam Papers (Practical and Theory)
• Feedback within 10 days of course end date

Copyright © 2018 Health and Social Care Information Centre. 22


National Clinical Coding Training Handbook 2018-19

Timing of the modules is key to support candidates during their revision.

4.3.1.3 Benefits to the delegate


• Provides an optimal revision environment
• Gives access to highly experienced and skilled Terminology and Classifications
Delivery Service Approved Clinical Coding Trainers
• Provides reinforcement of the correct application of the national clinical coding
standards for both ICD-10 and OPCS-4
• Opportunity to refresh and consolidate existing practical coding skills for ICD-10 and
OPCS-4
• Opportunity to refresh and consolidate existing theoretical coding skills for ICD-10 and
OPCS-4
• Opportunity to refresh and consolidate existing medical terminology and anatomy and
physiology knowledge
• Opportunity to refresh and consolidate existing knowledge on miscellaneous issues
such as SNOMED CT, uses of coded data, clinical coding audit, supplementary
classifications, National Tariff Payment System
• Provides guidance on developing a structured study plan to suit individual needs
• Provides the delegate with comprehensive revision workbooks covering all elements
of the National Clinical Coding Qualification (UK)
• Identifies any areas for further delegate revision
• Increases delegate confidence to sit the National Clinical Coding Qualification (UK)
through mock examinations, practical activities, group discussions and ongoing
revision support throughout the programme
• Can provide an opportunity to network with experience clinical coders from other
organisations who have the same objective to become Accredited Clinical Coders.
4.3.1.4 Benefits to the organisation
• Set of rigorous objectives that delegates are assessed against to support their
revision for the National Clinical Coding Qualification (UK)
• A blended approach to revision reinforcing all elements that could be included in the
National Clinical Coding Qualification (UK)
• Classroom-led revision by a learner-focused Approved Clinical Coding Trainer who
can deliver formal clinical coding training that complies with the Clinical Coding
Trainer Framework and is engaging to all experienced clinical coders
• Delivery / facilitation by a skilled Approved Clinical Coding Trainer who understands
the need for continued professional development and accreditation for the profession
and the need for accurate, high quality coded clinical data to support healthcare
planning, reimbursement, management of services, statistical analysis and research
• Increased effectiveness of formal training events and of learning transferred to the
workplace through ongoing online evaluation

Copyright © 2018 Health and Social Care Information Centre. 23


National Clinical Coding Training Handbook 2018-19

• The opportunity to deliver a more cost-efficient in-house revision programme to satisfy


internal data quality, Data Security and Protection Standard 3, Clinical Governance
and other NHS regulatory body requirements.
4.3.1.5 Attendance Criteria
This Programme is only available to experienced clinical coders employed within an NHS
Trust (including a Mental Health Trust) or an independent sector treatment centre (ISTC)
which treats and codes consultant episodes for NHS patients.
By the end of Module 1 of the Programme delegates will be able to:
• Draft an outline study plan using the template provided if they haven’t already created
a study plan.
• From memory, list five references found in the Bibliography that can support a NCCQ
(UK) Candidate study for Paper 1 – Practical Coding
• From memory, list three references found in the Bibliography that can support a
NCCQ (UK) Candidate study for Paper 2 – Theory
• Accurately complete the full index trails for all codes in the two given case studies
using your ICD-10 and OPCS-4 Alphabetical Indexes
• Correctly answer at least 50 out of 58 questions for Exercise 1 in the Anatomy and
Physiology Workbook with minimal reference to notes/books
• In pairs or groups list at least 10 benefits of SNOMED CT to different users in the
given flipchart activity and feedback to the rest of the group OR
• In pairs or groups define both a Classification and Terminology, list both the
differences between them and at least 5 uses of each, in the given flipchart activity
and feedback to the rest of the group.
• Correctly answer 2 out of the 3 given SNOMED CT questions with minimal reference
to notes
• Score a minimum of 95% in both the ICD-10 and OPCS-4 Organisation and Structure
exercises with reference to the National Clinical Coding Standards ICD-10 5th Edition
and OPCS-4 reference books only where essential
• Correctly answer all questions in the ICD-10 and OPCS-4 Four Step Coding Process
exercises using your Alphabetical Indexes and Tabular Lists.
By the end of Module 2 of the Programme delegates will be able to:
• Select the correct option to at least 6 of the multiple choice miscellaneous issues
questions with minimum reference to notes.
• Complete SNOMED CT, Anatomy and Physiology, Medical Terminology and ICD-10
and OPCS-4 theory questions to at least 60% accuracy.
• Assign ICD-10 and OPCS-4 codes to the practical questions to at least 90%
accuracy.
• Discuss accurate code assignment to the four given case studies as a group.
• Accurately complete the full index trails and score at least 90% in the given case
study using your ICD-10 and OPCS-4 Alphabetical Index and Tabular Lists only.
By the end of Module 3 of the Programme delegates will be able to:

Copyright © 2018 Health and Social Care Information Centre. 24


National Clinical Coding Training Handbook 2018-19

• 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

Copyright © 2018 Health and Social Care Information Centre. 25


National Clinical Coding Training Handbook 2018-19

• Sitting the mock examination paper(s) in examination conditions


Ongoing requirements
• Mandatory three-yearly Clinical Coding Standards Refresher Corse training
• Specialty workshops
• Approved Clinical Coding Trainer and/or Approved Clinical Coding Auditor (where
desired)
4.3.1.7. Programme Materials
Each delegate receives:
• Delegate Programme folder
• Reference Handouts
• Self-Learning Workbook
• Anatomy and Physiology Workbook (and Answer Book)
• Anatomy and Physiology Diagrams Slide Deck
• NCCQ (UK) Revision Workbook (and Answer Book)
• Numerous additional revision aids
• Mock examination feedback report
• Certificate of Successful Completion
4.3.1.8. Reference Materials
The delegate’s line manager must ensure their delegate has a copy of the following (either in
hard copy or electronic format) for use during the NCCQ (UK) Revision Programme and
ongoing study:
• Volumes 1 and 3 of ICD-10 5th Edition (fully updated to reflect the errata published in
the Coding Clinic Ref 112)
• OPCS-4.8 Volumes I and II
• National Clinical Coding Standards ICD-10 5th Edition reference book (2018)*
• National Clinical Coding Standards OPCS-4 reference book (2018)*
• OPCS-4.8 Supplementary Information Book*
• National Tariff Chemotherapy Regimens List*
• National Tariff High Cost Drug List*
• Chemotherapy Regimens Clinical Coding Standards and Guidance OPCS-4*
• High Cost Drugs Clinical Coding Standards OPCS-4*
• Basic Anatomy and Physiology Instruction Manual*
NB: Delegates are welcome to bring laptops/tablets to access electronic versions of the
products highlighted with an * during the Programme. These can be found on the Key
Publications page on Delen
Delegates may also use the OPCS-4.8 e-Version and ICD-10 e-Version*. These products
can also be downloaded via Delen
Coding Clinic Ref 88: Coding of Co-morbidities
NB: Delegates can download the latest version of the Coding Clinic onto their laptops/tablets
if desired. This can be found on the Key Publications page on Delen

Copyright © 2018 Health and Social Care Information Centre. 26


National Clinical Coding Training Handbook 2018-19

4.3.1.9. Course Timings


The course timings are:
Module 1 (Day 1): 09.00 – 16.45
Module 1 (Day 2): Optional so times may vary
Module 2 (Day 2): 09.00 – 16.45
Module 2 (Day 3): 09.00 – 16.45
Module 3 (Day 4): 09.00 – 16.45
4.3.1.10. Delegate Responsibilities – Summary
The delegate is responsible for:
• Ensuring punctuality at all time
• Respecting the Programme trainer and fellow delegates
• Attending the Modules applicable to their individual examination requirements
• Completing the NCCQ (UK) Revision Programme Pre-Information and Pre-requisites
form and emailing to the Programme trainer by the required timeframe
• Completing the Self-Learning Workbook before Module 2
• Working through their individual study plan using the revision aids provided and
according to the timeframes identified in their study plan.
4.3.1.11. Line Manager Responsibilities – Summary
The line manager is responsible for:
• Ensuring their clinical coder is fully supported during the 6-month revision programme
(including self-study) by allowing them the time to complete all relevant Modules and
personal study time in-between modules
• Ensuring availability of all reference products described in Section 4.3.1.8 above
• Providing ongoing support to their clinical coder to ensure sufficient time and
resources are available for completion of the desirable eLearning packages where
needed as part of their revision
• Allowing time for their clinical coder to attend any relevant Webinars.
4.3.1.12. Next Steps
Successful completion will result in compliance with Data Security and Protection Toolkit
Standard 3.

5 Other Useful Information


The information below provides links to other optional courses and eLearning available to
coders as part of their ongoing continued professional development.

5.1 The Health Informatics Career Framework (HICF)


The HICF provides a structure for careers within Health Informatics
https://www.hicf.org.uk/Index.aspx

Copyright © 2018 Health and Social Care Information Centre. 27


National Clinical Coding Training Handbook 2018-19

5.2 Informed: An introduction to the use of informatics in


healthcare
This is an e-learning course developed by the Department of Health. The course is available
for NHS employees who want to expand their knowledge of health informatics: http://www.e-
lfh.org.uk/programmes/health-informatics/

5.3 SNOMED CT Foundation Course


This is an eLearning course developed by SNOMED International. The course is available
to anyone seeking to acquire or demonstrate a broad foundational knowledge of SNOMED
CT.

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

5.4 Introduction to SNOMED CT Webinars


This webinar will give a good basic understanding of SNOMED CT, plus examples of
where it is used. Please select a webinar date below and register. Confirmation will be
emailed to you. You can join the webinars early to get set up.
https://digital.nhs.uk/article/762/SNOMED-CT-webinars

NB: Do not access the Introducing SNOMED CT in general practice webinar

5.5 NHS Data Dictionary eLearning


There are demonstrations available developed by the NHS Digital (HSCIC) which cover a
wide range of topics within the Data Dictionary. These can be accessed on a modular basis
depending on the information required.

Knowledge can be tested by the completion of quizzes.

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

Copyright © 2018 Health and Social Care Information Centre. 28

You might also like