Rules and Conventions of OPCS Flashcards
What is the definition of an intervention? (PRule1)
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
* associate 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 special facilities or equipment only available in an acute care setting.
What is the main axis of classification within OPCS?
Body system
What are the 4 different levels of complexity of procedures and give examples of each.
- Major - Total removal, Functional replacement, Transplant
- Intermediate - Partial removal, Partial destruction, Reconstruction, Repair
- Minor - Biopsy, Incision, Aspiration
- Non-operative procedures - Injection, Examination, Scan/Imaging, Screening
What is the purpose of overflow categories in OPCS-4?
When additional operations/interventions are required to be classified to a chapter that is full, overflow categories are created at the end of the chapter.
Overflow categories take the same structure as other categories but are assigned the letter O, no matter which chapter they are in.
Which chapters contain overflow categories?
- Chapter L - Arteries and Veins
- Chapter W - Other Bones and Joints
- Chapter Y - Subsidiary Classification of Methods of Operation
- Chapter Z - Subsidiary Classification of Site of Operation
.8 and .9 codes are found at both principle and extended categories. Which can be used and what is the purpose of having .8 and .9 at both?
- .8 and .9 codes can only be used from the principle categories
- the extended categories still contain .8 and .9 eventhough they are not for use, to maintain the structure of the classification
How are codes from overflow categories identified in the Alphabetical Index?
With the letter of the chapter the overflow category is contained within in brackets at the end of the index entry.
What is the purpose of extended categories within OPCS?
When additional procedures need to be classified to a category that is full, ‘extended categories’ are created as an extention to the ‘principle category’.
What position must codes from chapters Y and Z be assigned?
Only ever in a secondary position
What is the purpose of codes from chapter Y?
To enhance codes from the body system chapters where this adds further information about the procedure that cannot be fully reflected by the assignment of the body system code.
What is the purpose of codes from chapter Z?
To define more specifically the site of the operation, including laterality.
What section of the Alphabetical Index are Surgical Eponyms found?
Section II
What is a surgical eponym?
A procedure either named after the surgeon that pioneered it, or the device used within it.
What needs to be remembered about assigning codes using the Alphabetical Index of Surgical Eponyms?
The Alphabetical Index of Surgical Eponyms must not be used to assign codes.
If an eponym if used in the medical record, the procedural information must be analysed to ensure that code assignment fully reflects the procedure performed.
If the coder is unsure what procedure the eponym describes, they must seek advice from the responsible consultant.
What section of the Alphabetical Index are Surgical Abbreviations found in?
Section III
What must the coder do when an abbreviation is mentioned within the medical record to describe a procedure?
- Analyse the procedural information to ensure the code and it’s description fully reflect the procedure performed
- If unsure, seek advice from the responsible consultant
What are the two cross references found in OPCS?
‘See’ and ‘See also’
What is the purpose of the two cross references found in the OPCS alphabetical index?
They ensure that all possible terms are referenced by the coder and explicitly direct the coder to other entries in the index…
- See - an explicit direction to look elsewhere
- See also - a reminder to look under another lead term if all the information cannot be found under the first lead term entry.
Which instructional notes are found within the Tabular list for OPCS?
- Includes
- Excludes
- Note
Describe the use of Includes notes within the OPCS Tabular list.
They 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.
Describe the use of Excludes notes within the OPCS Tabular list.
They 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.
Describe the use of Notes within the OPCS Tabular list.
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)
Which paired codes notes appear in the OPCS Tabular List and what do they mean?
- 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/Use as a subsidiary code - use the code, at which this note appears in a secondary position
Which abbreviations are found in the OPCS Tabular List and Alphabetical Index?
- HFQ (However Further Qualified)
- NEC (Not Elsewhere Classified)
- NFQ (Not Further Qualified)
- NOC (Not Otherwise Classifiable)
What is meant by the abbreviation HFQ?
However Further Qualified - the procedure may be described in a number of ways, which will not affect the code assignment. It makes no difference how much more specific the clinician is in their statement, there is only one code option for that intervention.
What is meant by the abbreviation NEC?
Not Elsewhere Classified - indicates that a more detailed variation of the term may be covered by another code (may be within the same 3 character category). If a more detailed code is not available then the NEC code is assigned.
What is meant by the abbreviation NFQ?
Not Further Qualified - only found in Chapter L. Signifies that the terms ‘iliac artery’ and ‘femoral artery’, not further qualified within the code description, should be understood to include the subsites listed in the note at category level.
What is meant by the abbreviation NOC?
Not Otherwise Classifiable - only used in Chapter Y and indicates these methods of operation codes are to be used only when they cannot be specifically coded to any chapter in the main classification.
