OPCS - Rules, Conventions and PGCS Flashcards
PRule 1: Definition of an intervention
Interventions are those aspects of clinical care carried out on patients undergoing treatment:
- For the prevention, diagnosis, care or relief of disease.
- For the correction of deformity or deficit, including those performed for cosmetic reasons
- Associated with pregnancy, childbirth or contraceptive or procreative management.
Typically, this will be: • Surgical in nature; and/or • Carries a procedural risk; and/or • Carries an anaesthetic risk; and/or • Requires specialist training; and/or • Requires specialist facilities or equipment only available in an acute care setting
PRule 2: Single procedure analysis and multiple coding
- The intervention selected for single procedure analysis should be the MAIN intervention or procedure performed during the consultant episode.
- Multiple interventions are often carried out simultaneously. In OPCS some combinations are encompassed within a single category whilst others are required to be coded separately.
- It is important that users of the classification follow the instructional notes provided to ensure correct selection and sequencing of codes.
PRule 3: Axis of the classification
24 chapters within the OPCS:
• 20 chapters covering individual body systems (Chapters A-T and U-W)
• 1 chapter for diagnostic imagining, testing and rehabilitation procedures (Chapter U)
• 1 chapter for miscellaneous procedures and operations covering multiple systems (Chapter X)
• Two additional chapters providing subsidiary classifications
o One for methods of operation (Chapter Y)
o One for sites and laterality of operation (Chapter Z)
The main axis of classification is body system. Within any particular body system, the axis is the organ and within any particular organ the axis is the specific operation/intervention. The operations/interventions are broadly listed in descending order of complexity and are generally sequenced in a way that reflects their significance in terms of resource use.
Levels of complexity:
Major – Total removal, Functional replacement, Transplant
Intermediate – Partial removal, partial destruction, reconstruction, repair
Minor – Biopsy, incision, aspiration
Non-operative – Injection, Examination, Scan/Imaging, Screening
In some chapter the major-minor hierarchy is not applicable or not as evident due to capacity issues.
PRule 5: Capacity, overflow categories and principal and extended categories
To maintain structure of OPCS .8 and .9 codes are available in both principal and extended categories. Only the .8 and .9 codes from the principal categories can be used.
Where a principal category is referred to in an instruction note the extended category must also be referenced. i.e if a principal category is excluded from code assignment so is it’s extended category.
When addition operations/interventions are required to be classified to a chapter but the chapter is full; overflow categories are created at the end of the chapter. Overflow chapters take the same structure as other chapters but are assigned the letter O no matter which chapter they are classified to.
Overflow categories can be found at the end of chapters L, W, Y, Z.
Within the alphabetical index codes classified within overflow categories are identified by placing the letter of the chapter the overflow category is contained within in brackets at the end of the index entry.
Extended categories exist when an existing category is full but additional procedures/interventions need to classify to that category, this then becomes the principal category. Navigation is achieved by the inclusion of a cross reference at both three character category headings of the principal and extended categories.
Extended categories are not always in numerical order but have sometimes been slotted into gaps within the classification.
PConvention 1: Cross references
Cross references are provided in the Alphabetical Index to ensure that all possible terms are referenced by the coder. Cross references explicitly direct the coder to other entries in the index:
See
This is an explicit direction to look elsewhere.
See also
This is a reminder to look under another lead term if all the information cannot be found under the first lead term entry.
PConvention 2: Instructional notes and paired codes
Instructional ‘Notes’ are used within the Tabular list at chapter level, three-character category and four-character code levels. There are three types of notes:
Includes notes
Includes notes clarify the content (intent) of the chapter, category or code to which the
note applies, and state what else is included within the chapter, category or code.
Excludes notes
Excludes notes are used to prevent a chapter, category or code from being used
incorrectly. They direct the coder away from an incorrect chapter, category or code and
direct to the correct place. A specific reference to the correct chapter, category or code is listed in brackets following the exclusion statement.
Note
Notes provide instructions for coding and may be used:
• to advise coders to include or omit additional or subsidiary codes
• to direct coders elsewhere in the classification to more appropriate categories
• to clarify the intended use of a particular chapter, category or code.
• to provide specific instructions on the correct sequencing of codes when used
together (paired codes)
Paired codes notes
Some interventions/procedures are frequently carried out together but are classified at separate codes or categories. Where this is the case the categories concerned contain instructional Notes to indicate the associated code and correct sequencing.
The following paired codes notes appear in the OPCS-4 Tabular List:
• ‘Use a supplementary code/Use an additional code/Use a subsidiary code’ - use
the code, at which this note appears in a primary position.
• ‘Use as a supplementary code/Use as an additional code/For use as a subsidiary
code/Use as a secondary code’ - use the code, at which this note appears, in a
secondary position.
Paired codes may be classified within the same or a different body system chapter. They can be used alone when only one intervention/procedure is performed.
PConvention 3: Abbreviations
Following abbreviations are used in the Tabular list and alphabetical index:
HFQ (However further qualified)
Signifies that a statement may be further qualified/described in a number of ways, which will no effect code assignment, it does not matter how much more specifically a clinical describes the intervention, only one code exists for that option in OPCS.
NEC (Not elsewhere classified)
Indicates that a more specific code may be available in the classification. Sometimes this may be within the same category, if a more detailed code is not available then the NEC code is assigned.
NFQ (Not further qualified)
Found in chapter L, signifies that the terms ‘iliac artery’ and femoral artery’, should be understood to include the subsites listen in the category note.
NOC (Not otherwise classifiable)
Found in chapter Y and indicates that these codes are only to be used when they cannot be specifically coded to any chapter in the main classification.
Two other abbreviations are found in the tabular index:
Greater than
< Less than
PGCS1: Endoscopic and minimal access operations that do not have a specific code
Endoscopic or minimally invasive procedures that do not have a specific code must be dual coded, the following codes and sequencing is required:
Open procedure code
Y74-Y76 minimal access approach code
o When more then one minimally invasive procedure has been undertaken an approach code must be assigned after each open procedure code.
Chapter Y code (if required)
Chapter Z site code(s)
Z94.- laterality (if applicable)
PGCS2: Diagnostic versus therapeutic procedures
If a diagnostic procedure proceeds to, or is undertaken at the same time as a therapeutic procedure on the same site then only the code for the therapeutic procedure is required, this includes:
- Diagnostic endoscopies performed prior to an open procedure
- Diagnostic endoscopies performed prior to a therapeutic endoscopic procedure. (As indicated by the instructional notes at all therapeutic endoscopic codes)
When a diagnostic (exploratory) laparotomy performed to search for possible pathology progresses to therapeutic procedure(s) as a result of the exploration, only the therapeutic procedure(s) is coded.
There are exceptions to this standard, for example:
- ERCP (J43) together with (J38) or (J39)
- D&C together with diagnostic hysteroscopy and uterine coil
- Therapeutic endoscopic procedure (excluding excisions) with biopsy.
If there is any doubt as to whether a procedure is diagnostic or therapeutic, clarification must be sought from the responsible consultant.
PGCS3: Incomplete, unfinished, abandoned and failed procedures
Incomplete, unfinished, abandoned and failed procedures (excludes failed procedures converted to open) must be coded to the stage of abandonment for the procedure; the intention must not be coded. However, if the intervention/procedure has reached the final stage and has been unsuccessful, it must be coded as if the whole procedure had been carried out.
The exception to this standard is PCSJ2: failed or abandoned endoscopic retrograde cholangiopancreatography J43.9
PGCS4: Failed percutaneous and minimal access procedures converted to open
When a minimal access or percutaneous transluminal approach procedure fails and is converted to an open procedure, during the same visit to theatre, the following codes and sequencing must be applied:
- Open procedure code
- Y71.4 failed minimal access approach converted to open or Y71.5 failed percutaneous transluminal approach converted to open
PGCS5: Unintentional procedures
Where an unintentional action, such as perforation of an organ, occurs during a procedure, this unintentional action must not be recorded using OPCS-4 codes.
Any surgical procedures performed to correct the unintentional action, e.g. suture of accidentally perforated organ, must be recorded using the appropriate OPCS-4 code(s).
PGCS6: Radical operations
When coding radical operation:
• Code assignment must fully reflect the procedure(s) performed during the radical operation
• Instructional Notes must be applied in order to fully reflect all procedures performed
• Any uncertainty as to what procedures were performed during the radical operation must be clarified with the responsible consultant in order to ensure correct code assignment.
PGCS9: Excision and biopsy procedures
When an excision and biopsy is performed on the same site during the same theatre visit (often referred to as an excision biopsy), only assign a code(s) for the excision, as a biopsy is an integral part of the excision.
How must therapeutic endoscopic procedures be coded?
Diagnostic endoscopic procedures
When multiple sites are examined during a diagnostic endoscopy, a sit code must be added to identify the furthest site examined (sites included are in category includes notes)
During a diagnostic endoscopy, if a biopsy is taken at the same time as multiple sites are examined, the site of the biopsy takes preference, therefore the site of the biopsy is the only site code required. This includes whether the site of the biopsy was not the furthest point examined.
Where multiple biopsies are taken, only a site for the furthest biopsy performed is required.
