The national clinical coding standards provide a reference source primarily aimed at clinical coders. The level of detail reflects the assumption that users will be trained in the use of the OPCS-4 classification as well as the abstraction of relevant information from the medical record. Authorised amendments to the reference book are compiled and issued only by NHS Digital - Clinical Classifications Service. This reference book of national clinical coding standards is an evolving product and builds on the previously issued OPCS-4 Clinical Coding Instruction Manual. As the main emphasis of clinical coding is data quality and accuracy this reference book will focus on the clinical coding standards that must be applied when assigning OPCS-4 codes. The national clinical coding standards provide a reference source primarily aimed at clinical coders. The level of detail reflects the assumption that users will be trained in the use of the OPCS-4 classification as well as the abstraction of relevant information from the medical record. Authorised amendments to the reference book are compiled and issued only by NHS Digital - Clinical Classifications Service. The classification is mandatory for use by Health Care Providers to support various forms of data collections, such as Central Returns and Commissioning Data Sets (CDS). All Consultant Episodes (hospital provider) containing procedures must be recorded and collected using OPCS-4. The requirements for data sets and related definitions are specified in the NHS Data Model and Data Dictionary.

This title gives specific instruction on the use of the ICD-10 classification for morbidity coding in areas of potential ambiguity to safeguard data consistency through national clinical coding standards. The National Clinical Coding Standards ICD-10 are for use with the World Health Organisation (WHO) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision 5th Edition (ICD-10) when translating diagnoses and other health related problems recorded in a patient's medical record for morbidity coding. The classification of diagnoses using ICD-10 is a mandatory national requirement for the NHS Admitted Patient Care (APC) Commissioning Data Set. Where a standard within the WHO ICD-10 Volume 2 differs to a national clinical coding standard, the national clinical coding standard must take precedence.

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

The OPCS Classification of Interventions and Procedures (OPCS-4) is a statistical classification of interventions and procedures undertaken in the National Health Service (NHS) reflecting current clinical practice. OPCS-4 is an approved NHS Fundamental Information Standard. This reference book of national clinical coding standards is an evolving product and builds on the previously issued OPCS-4 Clinical Coding Instruction Manual. As the main emphasis of clinical coding is data quality and accuracy this reference book will focus on the clinical coding standards that must be applied when assigning OPCS-4 codes.

This manual is intended to be used as a basic instruction tool. It will help promote an understanding of diseases and operations described in casenotes by providing information on body systems, how they work together, and the terminology used to describe them. The intended result is that those responsible for clinical coding will be better able to translate these concepts into the appropriate clinical codes. This instruction manual explains and illustrates the body system by system. To assist the reader in understanding individual systems, each chapter is provided with full colour diagrams, exercises and a glossary of relevant terms.

This open access book comprehensively covers the fundamentals of clinical data science, focusing on data collection, modelling and clinical applications. Topics covered in the first section on data collection include: data sources, data at scale (big data), data stewardship (FAIR data) and related privacy concerns. Aspects of predictive modelling using techniques such as classification, regression or clustering, and prediction model validation will be covered in the second section. The third section covers aspects of (mobile) clinical decision support systems, operational excellence and value-based healthcare. Fundamentals of Clinical Data Science is an essential resource for healthcare professionals and IT consultants intending to develop and refine their skills in personalized medicine, using solutions based on large datasets from electronic health records or telemonitoring programmes. The book’s promise is “no math, no code”and will explain the topics in a style that is optimized for a healthcare audience.