Accredited Clinical Coder
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Accredited Clinical Coder
The National Clinical Coding Qualification (UK) (NCCQ) is a professional examination for clinical coders working in the United Kingdom. Currently, it is the only clinical coding qualification recognised by the NHS. Having the NCCQ is a requirement of being admitted to the National Clinical Coding Trainer and Auditor Programmes run by NHS Digital. In order for an acute trust to obtain level 2 of the Information Governance Toolkit (IGT) requirement 510, they are expected to support coding staff in attaining the NCCQ. Upon passing the examination a clinical coder is awarded the designation Accredited Clinical Coder (ACC). Development In 1998 the Chief Executive of the former NHS Centre for Coding and Classifications (NHS CCC) initiated work to establish a national clinical coding qualification appropriate for the NHS. The NHS CCC developed a prototype assessment with results reported at the end of February 1998. On 10 March 1998, the NHS CCC hosted a workshop with educational org ...
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Clinical Coder
A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The Health data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education. For example, a clinical coder may use a set of published codes on medical diagnoses and procedures, such as the International Classification of Diseases (ICD), the Healthcare Common procedural Coding System (HCPCS), and Current Procedural Terminology (CPT) for reporting to the health insurance provider of the recipient of the care. The u ...
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United Kingdom
The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the European mainland, continental mainland. It comprises England, Scotland, Wales and Northern Ireland. The United Kingdom includes the island of Great Britain, the north-eastern part of the island of Ireland, and many List of islands of the United Kingdom, smaller islands within the British Isles. Northern Ireland shares Republic of Ireland–United Kingdom border, a land border with the Republic of Ireland; otherwise, the United Kingdom is surrounded by the Atlantic Ocean, the North Sea, the English Channel, the Celtic Sea and the Irish Sea. The total area of the United Kingdom is , with an estimated 2020 population of more than 67 million people. The United Kingdom has evolved from a series of annexations, unions and separations of constituent countries over several hundred years. The Treaty of Union between ...
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National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the "NHS" name ( NHS England, NHS Scotland and NHS Wales). Health and Social Care in Northern Ireland was created separately and is often locally referred to as "the NHS". The four systems were established in 1948 as part of major social reforms following the Second World War. The founding principles were that services should be comprehensive, universal and free at the point of delivery—a health service based on clinical need, not ability to pay. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom apart from dental treatment and optical care. In England, NHS patients have to pay prescription charges; some, such as those aged over 60 and certain state ...
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NHS Digital
NHS Digital is the trading name of the Health and Social Care Information Centre, which is the national provider of information, data and IT systems for commissioners, analysts and clinicians in health and social care in England, particularly those involved with the National Health Service of England. The organisation is an executive non-departmental public body of the Department of Health and Social Care. Role NHS Digital provides digital services for the NHS and social care, including the management of large health informatics programmes. They deliver national systems through in-house teams, and by contracting private suppliers. These services include managing patient data including the Spine, which allows the secure sharing of information between different parts of the NHS, and forms the basis of the Electronic Prescription Service, Summary Care Record and Electronic Referral Service. NHS Digital is also the national collator of information about health and social care, an ...
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Hospital Trust
A hospital trust, also known as an acute trust, is an NHS trust that provides secondary health services within the English National Health Service and, until they were abolished, in NHS Wales. Hospital trusts were commissioned to provide these services by NHS primary care trusts and now by clinical commissioning groups. NHS trusts were established by the National Health Service and Community Care Act 1990 as the first step in setting up an internal market. NHS foundation trusts were regulated by Monitor until 2016, when it was merged with the NHS Trust Development Authority to form NHS Improvement. As of January 2014, there were 59 NHS hospital trusts, out of the total of 97 NHS trusts supervised by the TDA.{{cite web, url=http://www.ntda.nhs.uk/wp-content/uploads/2014/03/winter_report_web-FINAL.pdf , title=Winter Report , publisher=NHS Trust Development Authority , access-date=29 March 2014 See also *List of NHS trusts *List of hospitals in England *List of hospitals in Wa ...
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Information Governance
Information governance, or IG, is the overall strategy for information at an organization. Information governance balances the risk that information presents with the value that information provides. Information governance helps with legal compliance, operational transparency, and reducing expenditures associated with legal discovery. An organization can establish a consistent and logical framework for employees to handle data through their information governance policies and procedures. These policies guide proper behavior regarding how organizations and their employees handle information whether it is physically or electronically created ( ESI). Information governance encompasses more than traditional records management. It incorporates information security and protection, compliance, data quality, data governance, electronic discovery, risk management, privacy, data storage and archiving, knowledge management, business operations and management, audit, analytics, IT manage ...
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ICD-10
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Work on ICD-10 began in 1983, became endorsed by the Forty-third World Health Assembly in 1990, and was first used by member states in 1994. It was replaced by ICD-11 on January 1, 2022. While WHO manages and publishes the base version of the ICD, several member states have modified it to better suit their needs. In the base classification, the code set allows for more than 14,000 different codes and permits the tracking of many new diagnoses compared to the preceding ICD-9. Through the use of optional sub-classifications, ICD-10 allows for specificity regarding the cause, manifestation, location, severity, and type of injury or disease. Th ...
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OPCS-4
OPCS-4, or more formally OPCS Classification of Interventions and Procedures version 4, is the procedural classification used by clinical coders within National Health Service (NHS) hospitals of NHS England, NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland. It is based on the earlier Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision), and retains the OPCS abbreviation from this now defunct publication. OPCS-4 codifies operations, procedures and interventions performed during in-patient stays, day case surgery and some out-patient treatments in NHS hospitals. Though the code structure is different, as a code set, OPCS-4 is comparable to the American Medical Association's Current Procedural Terminology. As a publication, OPCS-4 is split into two volumes; a tabular list (Volume I) and an alphabetical index (Volume II). An electronic version is also available. However, a number of supplementary pub ...
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SNOMED CT
SNOMED CT or SNOMED Clinical Terms is a systematically organized computer-processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens. SNOMED CT is maintained and distributed by SNOMED International, an international non-profit standards development organization, located in London, UK. SNOMED International is the trading name of the Inte ...
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Post-nominal Letters
Post-nominal letters, also called post-nominal initials, post-nominal titles, designatory letters or simply post-nominals, are letters placed after a person's name to indicate that the individual holds a position, academic degree, accreditation, office, military decoration, or honour, or is a member of a religious institute or fraternity. An individual may use several different sets of post-nominal letters, but in some contexts it may be customary to limit the number of sets to one or just a few. The order in which post-nominals are listed after a name is based on rules of precedence and what is appropriate for a given situation. Post-nominal letters are one of the main types of name suffix. In contrast, pre-nominal letters precede the name rather than following it, such as addressing a physician or professor as "Dr. Smith". List Different awards and post-nominal letters are in use in the English-speaking countries. Usage Listing order The order in which post-nominal le ...
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