Clinical Coding Training and Audit Prospectus

Clinical Coding Training and Audit Prospectus An NCS Clinical Coding Academy

Welcome Clinical Coding Training and Audit High quality data is crucial for informing strategic and local decisions for capacity and service planning well as understanding clinical performance and outcomes. Equally, accurate payment made under Payment by Results is dependent upon high quality data and high quality data is dependent upon highly skilled clinical coders and a robust programme of clinical coding audit. As an NCS Clinical Coding Academy we have established a programme of clinical coding training and clinical coding audit that replicates the standards developed by the National Classifications Service and all of our courses, workshops and audits are delivered either by Connecting for Health (CfH) accredited clinical coding trainers using CfH developed or endorsed materials, or CfH approved clinical coding auditors using clinical coding audit methodology version 4.0. In recognition of the investment that NHS Trusts have made in supporting clinical coders to develop into clinical coding trainers, we are able to support apprentice clinical coding trainers in gaining the competence and confidence required to reach experienced trainer status by offering opportunities for co-delivery of foundation level training with an experienced trainer. In addition, we are now qualified to undertake promotion assessments for apprentice clinical coding trainers, TAP re-certification assessments and clinical coding audit report assessments. Finally, we are currently working with the National Classifications Centre to develop a model of affiliation where NHS Trust employed trainers and auditors can affiliate with an Academy to benefit from collaborative working, sharing best practice and maximising the return on NHS resources. If you do have specific training or audit needs, or wish to know more about the services offered by the Academy, then please do not hesitate to contact us at mary.jacklin@this.nhs.uk Accreditations & Awards ISO 27001 FS 547581 ISO 9001 FS 547579 2 Clinical Coding Training and Audit

Clinical Coding Foundation Course 5 Introduction 5 Attendance Criteria 5 Learning Outcomes 5 Benefits to the Delegate and Employer 6 Course Materials 6 Reference Materials 6 Course Timings 7 Registration 7 Accommodation 7 Clinical Coding Refresher Course 8 Introduction 8 Attendance Criteria 8 Learning Outcomes 8 Benefits to the Delegate and Employer 9 Course Materials 9 Reference Materials 9 Course Timings 10 Registration 10 Accommodation 10 Mental Health Foundation Course 11 Introduction 11 Attendance Criteria 11 Learning Outcomes 11 Benefits to the Delegate and Employer 11 Course Materials 11 Reference Materials 12 Course Timings 12 Registration 12 Accommodation 12 Circulatory and Vascular Specialty Workshop 13 Introduction 13 Attendance Criteria 13 Learning Outcomes 13 Benefits to the Delegate and Employer 13 Course Materials 13 Reference Materials 14 Course Timings 14 Registration 14 Accommodation 14 Orthopaedics Clinical Coding Workshop 15 Introduction 15 Attendance Criteria 15 Learning Outcomes 15 Benefits to the Delegate and Employer 15 Course Materials 15 Reference Materials 16 Course Timings 16 Registration 16 Accommodation 16 Obstetric & Perinatal Clinical Coding Workshop 17 Introduction 17 Attendance Criteria 17 Learning Outcomes 17 Benefits to the Delegate and Employer 17 Course Materials 17 Reference Materials 18 Course Timings 18 Registration 18 Accommodation 18 Contents www.this.nhs.uk Contents 3

Contents Contents NCCQ (UK) Revision Workshop 19 Introduction 19 Attendance Criteria 19 Learning Outcomes 19 Benefits to the Delegate and Employer 19 Course Materials 20 Reference Materials 20 Course Timings 20 Registration 21 Accommodation 21 Important Supplementary Information 21 Neoplasm Workshop 22 Introduction 22 Attendance Criteria 22 Learning Outcomes 22 Benefits to the Delegate and Employer 22 Course Materials 22 Reference Materials 23 Course Timings 23 Registration 23 Accommodation 23 Clinical Coding Audit 24 Introduction 24 Attendance Criteria 24 Learning Outcomes 24 Benefits to the Delegate and Employer 24 Course Materials 24 Reference Materials 25 Course Timings 25 Registration 25 Accommodation 25 Apprentice Trainer Support 26 Apprentice Trainer and TAP Re-Certification Assessments 27 Apprentice Trainer Support 28 Registration Terms and Conditions 29 The Fees 29 Cancellations 29 Accommodation 29 Copyright 29 Course Content 30 Course Dates and Venues 30 On-Site Courses 30 Data Protection 30 Delegate Code of Conduct 31 4 Clinical Coding Training and Audit

Clinical Coding Foundation Course Introduction An 18 day course of classroom-based training developed and updated by the NHS Classifications Service and delivered by The Health Informatics Service. The course is divided into four modules delivered over a three month period and provides formal training in the use of the classifications ICD-10 and OPCS-4 mandated within the NHS. The course aims to provide the novice coder with a thorough grounding in the theory of classifications as well as opportunities to develop practical skills in clinical coding. In-between modules the delegate has the opportunity to gain experience of understanding case note format and locally used coding systems back in their workplace. Attendance Criteria Delegates must be working in the NHS and have been recently recruited into a clinical coding profession. They should possess little knowledge on the subject and have not previously attended a clinical coding foundation course. Foundation Course This course is aimed at novice coders who are already working within the clinical coding fraternity. If you are not working as a clinical coder, it is recommended you wait until you are in an appropriate post before applying to attend this course. You can obtain details about working as a clinical coder from your local Trust s HR department or the NHS Careers website (http://www.nhscareers.nhs.uk/). Learning Outcomes At the end of this course delegates will be able to: Understand the uses and importance of coded clinical data for local purposes Appreciate the wider uses of coded clinical data for healthcare planning, reimbursement (Payment by Results), management of services, statistical analysis and research Appreciate the use of coded clinical data as part of the electronic health record within the NHS Care Records Service Understand the structure and principles of the ICD-10 and OPCS-4 classifications currently mandated in the NHS Understand and apply the rules and conventions of each classification Understand clinical coding methodology and consistently apply the four step coding process for both ICD-10 and OPCS-4 Understand the national definition of a primary diagnosis and consistently apply this when assigning ICD-10 codes Accurately identify and assign the correct primary diagnosis and co-morbidities for a range of typical case note scenarios Understand the national intervention definition and selection of main procedure and consistently apply this when assigning OPCS-4 codes Accurately identify and assign the correct primary and secondary procedures to a range of typical case note scenarios Understand diseases and operations through the study of basic anatomy, physiology and medical terminology typically described in case notes Develop the confidence required to code case notes back in the workplace through participation in a number of interactive reinforcement activities. www.this.nhs.uk 5

Foundation Course 6 Clinical Coding Foundation Course Benefits to the Delegate and Employer Provision of an optimal learning environment An understanding of the role and importance of clinical coding within their working environment and in particular the impact of Payment by Results Receive instruction compliant with national standards set by the NHS Classifications Service Provision of national standard training materials Modular assessments and end of course report provided to delegate and line manager to be used as a baseline for delegate s future development plan Access to a highly experienced and skilled NHS NHS Classifications Service Approved Clinical Coding Trainer (regularly assess to ensure continued high quality delivery) Opportunity to network with novice clinical coders from other organisations Contributes towards studying for the National Clinical Coding Qualification (UK) Names added to The Health Informatics Service Customer Database to receive updates to publications, e-bulletin notifications Course Materials Each delegate receives: NHS Classifications Service ICD-10 Clinical Coding Instruction Manual NHS Classifications Service OPCS-4 Clinical Coding Instruction Manual NHS Classifications Service Basic Anatomy and Physiology Instruction Manual NHS Classifications Service ICD-10 and OPCS-4 Question and Answer Books Delegate Course Folder including exercise and information handouts End of module assessment results and an informal report to delegate and line manager at the end of the course NHS Classifications Service Certificate of completion of course Reference Materials Each delegate must supply their own reference books for use during the course: World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) Medical Dictionary Please note: Failure to turn up to the course with the correct reference materials will result in removal from the course. Clinical coders working within the NHS also have access to the following interactive e-learning modules developed by NHS Classifications Service via its website (http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred/elearning): Four Step Coding Process for ICD-10 Anatomy and Physiology These e-learning modules can be used prior to attendance on a Clinical Coding Foundation Course or, more usefully, as knowledge-reinforcement tools following attendance on this course. Clinical Coding Training and Audit

Course Timings Tuition time is 09:00 16:45 except for Day 1 of each module which starts at 10:00 and the last day of each module which ends at 15:30. Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Foundation Course Foundation Course Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. Crown Copyright www.this.nhs.uk 7

Refresher Course Clinical Coding Refresher Course Introduction A 4 day course of classroom-based training developed and updated by the NHS Classifications Service and delivered by The Health Informatics Service. The course aims to consolidate both the practical coding skills and theoretical knowledge of the experienced clinical coder through a number of assessment based exercises and interactive activities. This course will also be offered as an e-learning module from 2010/11 onwards at (http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred/elearning). Attendance Criteria This course is suitable for any clinical coder who has completed either the clinical coding foundation course in the last two years, or who has not updated their coding skills in the last three years. Delegates must have a minimum of two years experience coding in a variety of specialties. This course is also highly recommended for anyone sitting the examinations to achieve the National Clinical Coding Qualification (UK). The NHS Classifications Service recommends that a Clinical Coder, Manager, Supervisor or Auditor attends a Refresher Course every three years to maintain and update their practical coding skills and theoretical knowledge. Learning Outcomes At the end of this course delegates will be able to: Understand and describe the role and importance of coded clinical data at local, national and international levels Understand the quality criteria of data: accuracy, consistency, completeness, timeliness and its role within Payment by Results Update their knowledge on national standards and guidance since basic training to ensure compliance with national clinical coding standards Refresh and consolidate existing practical coding skills and four step coding process for ICD-10 and OPCS-4 Refresh and consolidate existing theoretical coding knowledge for ICD-10 and OPCS-4 Apply this knowledge to consistently and accurately identify the correct codes for a range of typical case note and more complex scenarios Increase self-confidence through participation in a number of interactive reinforcement activities Monitor their progress through the ongoing assessment which features as part of this course 8 Clinical Coding Training and Audit

Clincal Coding Refresher Course Benefits to the Delegate and Employer Provision of an optimal learning environment Provides an opportunity to enhance delegates knowledge in all aspects of clinical coding Adds value to the delegate and their employing organisation by ensuring compliance with current national clinical coding standards Provision of national standard training materials Access to highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainers (regularly assessed to ensure continued high quality delivery) Opportunity to network with experienced clinical coders from other organitions Supports delegate and employers commitment to Continued Professional Development Contributes towards studying for the National Clinical Coding Qualification (UK) Assessments and end of course report provided to delegate and line manager as a baseline for delegate s future development plan Course Materials Each delegate receives: Delegate Course Folder containing a Workbook and several handouts NHS Classifications Service ICD-10 and OPCS-4 Question and Answer Books A copy of certain exercise scores from the 4 day course and an informal progress report will be sent to delegates and their line managers at the end of the course NHS Classifications Service Certificate of completion of course Reference Materials Each delegate must supply their own reference books for use during the course: World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) Current version of OPCS-4.4 Chemotherapy Regimen NHS Classifications Service ICD-10 Clinical Coding Instruction Manual (current version) NHS Classifications Service OPCS-4 Clinical Coding Instruction Manual (current version) Coding Clinic Collection Refresher Course Clinical Coders working within the NHS also have access to the following interactive e-learning modules developed by NHS Classifications Service via its website (http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred/elearning): Four Step Coding Process for ICD-10 Anatomy and Physiology These e-learning modules can be used at any time by the experienced clinical coder as knowledge reinforcement tools. www.this.nhs.uk 9

Refresher Course Clincal Coding Refresher Course Course Timings Tuition time is 09:00 16:45 except Day 1 of the course which starts at 10:00 and Day 4 which finishes at 15:30. Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. 10 Clinical Coding Training and Audit Crown Copyright

Mental Health Foundation Course Introduction A 3 day course of classroom-based training developed and updated by the NHS Classifications Service and delivered by The Health Informatics Service. The workshop offers specialty training to enable experienced clinical coders to further develop their knowledge and understanding of the processes and terminology associated with mental health. Attendance Criteria To benefit from this workshop, it is essential that participants have already completed a clinical coding foundation course using the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals. Foundation Course Learning Outcomes At the end of this workshop delegates will be able to: Accurately comply with national standards, rules, conventions and best practice pertaining to mental health coding Understand more complex areas of case note extraction associated with mental health coding, including: - Definitions - Terminology Understand and apply coding principles to mental health case study scenarios There will be no formal assessment but delegates will work through a range of exercises, quizzes and interactive reinforcement activities. Benefits to the Delegate and Employer Unique workshop developed by The Health Informatics Service to specifically meet the needs of clinical coders in the study and coding of mental health episodes to satisfy the requirements of Payment by Results Provision of an optimal learning environment Development of a greater understanding and knowledge about mental health systems processes and terminology Ability to understand and accurately code complex mental health scenarios Access to a highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainer Opportunity to network with other experienced clinical coders Contributes towards studying for the National Clinical Coding Qualification (UK) Course Materials Delegate Course Folder including written exercises NHS Classifications Service Certificate of completion of course www.this.nhs.uk 11

Foundation Course Mental Health Foundation Course Reference Materials World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) Medical Dictionary Course Timings Tuition time is 09:00 16:45 except Day 1 of the course which starts at 10:00 and Day 3 which finishes at 15:30. Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. 12 Clinical Coding Training and Audit Crown Copyright

Circulatory and Vascular Specialty Workshop Introduction A 4 day workshop of classroom-based training developed and updated by the NHS Classifications Service and delivered by The Health Informatics Service. The workshop offers specialty training to enable experienced clinical coders to further develop their knowledge and understanding of the processes and terminology associated with the Circulatory and Vascular systems. Attendance Criteria To benefit from this workshop, it is essential that participants have already completed a clinical coding foundation course using the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals. Specialty Workshop Learning Outcomes At the end of this workshop delegates will be able to: Accurately comply with national standards, rules, conventions and best practice pertaining to circulatory and vascular coding Understand more complex areas of case note extraction associated with circulatory and vascular coding, including: - Definitions - Terminology Understand and apply coding principles to circulatory and vascular case study scenarios There will be no formal assessment but delegates will work through a range of exercises, quizzes and interactive reinforcement activities. Benefits to the Delegate and Employer Unique workshop developed by The Health Informatics Service to specifically meet the needs of clinical coders in the study and coding of circulatory and vascular episodes to satisfy the requirements of Payment by Results Provision of an optimal learning environment Development of a greater understanding and knowledge about circulatory and vascular systems processes and terminology Ability to understand and accurately code complex circulatory and vascular scenarios Access to a highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainer Opportunity to network with other experienced clinical coders Contributes towards studying for the National Clinical Coding Qualification (UK) Course Materials Delegate Course Folder including written exercises NHS Classifications Service Certificate of completion of course www.this.nhs.uk 13

Specialty Workshop Circulatory and Vascular Specialty Workshop Reference Materials World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) Medical Dictionary Course Timings Tuition time is 09:00 16:45 except Day 1 of the course which starts at 10:00 and Day 4 which finishes at 15:30. Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. 14 Clinical Coding Training and Audit Crown Copyright

Orthopaedics Clinical Coding Workshop Introduction A 4 day workshop of classroom-based training developed and updated by the NHS Classifications Service and delivered by The Health Informatics Service. The workshop offers specialty training to enable experienced clinical coders to further develop their knowledge and understanding of the processes and terminology associated with orthopaedics. Workshop Attendance Criteria To benefit from this workshop, it is essential that participants have already completed a clinical coding foundation course using the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals. Learning Outcomes At the end of this workshop delegates will be able to: Accurately comply with national standards, rules, conventions and best practice pertaining to orthopaedics coding Understand more complex areas of case note extraction associated with orthopaedics coding, including: - Definitions - Terminology Understand and apply coding principles to orthopaedics case study scenarios There will be no formal assessment but delegates will work through a range of exercises, quizzes and interactive reinforcement activities. Benefits to the Delegate and Employer Unique workshop developed by The Health Informatics Service to specifically meet the needs of clinical coders in the study and coding of orthopaedic episodes to satisfy the requirements of Payment by Results Provision of an optimal learning environment Development of a greater understanding and knowledge about orthopaedics systems processes and terminology Ability to understand and accurately code complex orthopaedics scenarios Access to a highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainer Opportunity to network with other experienced clinical coders Contributes towards studying for the National Clinical Coding Qualification (UK) Course Materials Delegate Course Folder including written exercises NHS Classifications Service Certificate of completion of course www.this.nhs.uk 15

Workshop Orthopaedics Clinical Coding Workshop Reference Materials World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) Medical Dictionary Course Timings Tuition time is 09:00 16:45 except Day 1 of the course which starts at 10:00 and Day 4 which finishes at 15:30. Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. 16 Clinical Coding Training and Audit Crown Copyright

Obstetric & Perinatal Clinical Coding Workshop Introduction A 3 day workshop of classroom-based training delivered by The Health Informatics Service. The workshop offers specialty training to enable experienced clinical coders to further develop their knowledge and understanding of the processes and terminology associated with the classification of obstetric & perinatal diagnoses and interventions. Workshop Attendance Criteria To benefit from this workshop, it is essential that participants have already completed a clinical coding foundation course using the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals. Learning Outcomes At the end of this workshop delegates will be able to: Accurately comply with national standards, rules, conventions and best practice pertaining to obstetric and perinatal coding Understand more complex areas of case note extraction associated with obstetric and perinatal coding, including: - Definitions - Terminology Understand and apply coding principles to obstetric and perinatal case study scenarios There will be no formal assessment but delegates will work through a range of exercises, quizzes and interactive reinforcement activities. Benefits to the Delegate and Employer Unique workshop delivered by The Health Informatics Service to specifically meet the needs of clinical coders in the study and coding of obstetric and perinatal episodes to satisfy the requirements of Payment by Results Provision of an optimal learning environment Development of a greater understanding and knowledge about the reproductive system. Ability to understand and accurately code complex obstetric and perinatal scenarios Access to a highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainer Opportunity to network with other experienced clinical coders Contributes towards studying for the National Clinical Coding Qualification (UK) Course Materials Delegate Course Folder including written exercises The Health Informatics Service Certificate of completion of course www.this.nhs.uk 17

Workshop Obstetric & Perinatal Clinical Coding Workshop Reference Materials World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) Medical Dictionary Course Timings Tuition time is Day 1 10:00 16:45 Day 2 9:00 16:45 Day 3 9:00 15:30 Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. 18 Clinical Coding Training and Audit Crown Copyright

NCCQ (UK) Revision Workshop Introduction A 3 day course of classroom-based training developed and updated by the NHS Classifications Service and delivered by The Health Informatics Service. This workshop supports delegates currently studying for the National Clinical Coding Qualification (UK) by providing advice on study techniques, refreshing basic clinical coding practical skills and theoretical knowledge including basic anatomy and physiology. The workshop also contains a mock examination and feedback session. This workshop will also be offered as an e-learning module from 2010/11 onwards at (http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred/elearning). Revision Workshop Attendance Criteria This workshop is available to any clinical coder studying for the National Clinical Coding Qualification (UK) examinations to become an Accredited Clinical Coder (ACC). Delegates will preferably have a minimum of two years clinical coding experience and must have previously attended Clinical Coding Foundation and ideally Refresher Course training. This course is aimed at staff already working within the clinical coding fraternity. If you are not working as a clinical coder, it is recommended you wait until you are in an appropriate post and have undergone the required Clinical Coding Foundation Course training before applying to attend this course. You can obtain details about working as a clinical coder from your local Trust s HR department or the NHS Careers website (http://www.nhscareers.nhs.uk/). Learning Outcomes At the end of this course delegates will understand and have further guidance in: How to prepare and study for the examination papers Taking an examination achieved by sitting a mock examination in full exam conditions Developing the skills required for all components of the qualification The basic principles of SNOMED Clinical Terms The delegate will also be able to increase their self-confidence through participation in a number of interactive activities Benefits to the Delegate and Employer Provision of an optimal learning environment Receive instruction compliant with national standards set by the NHS Classifications Service Access to highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainers (regularly assessed to ensure continued high quality delivery) Opportunity to network with experienced clinical coders from other organisations www.this.nhs.uk 19

Revision Workshop NCCQ (UK) Revision Workshop Course Materials Each delegate receives: Delegate Course Folder and all exercises and handouts NHS Classifications Service ICD-10 and OPCS-4 Question and Answer Books to aid their revision Relevant SNOMED CT articles NHS Classifications Service Certificate of completion of course Reference Materials Each delegate must supply their own reference books for use during the course: World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1, 2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) NHS Classifications Service ICD-10 Clinical Coding Instruction Manual (current version) NHS Classifications Service OPCS-4 Clinical Coding Instruction Manual (current version) NHS Classifications Service Basic Anatomy and Physiology Instruction Manual Please note: Failure to turn up to the course with the correct reference materials will result in removal from the course. Clinical Coders working within the NHS also have access to the following interactive e-learning modules developed by NHS Classifications Service via its website (http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred/elearning): Four Step Coding Process for ICD-10 Anatomy and Physiology These e-learning modules can be used at any time by the experienced clinical coder as knowledge reinforcement tools. NHS-based coders can also access a number of past full and mock examination papers to further aid their revisions available to download at http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred/accreditation/exam_papers Course Timings Tuition time is 09:00 17:00 except Day 3 which finishes at 15:45 20 Clinical Coding Training and Audit

Registration Complete a Training Course Registration Form and submit to The Health Informatics Service: By e-mail to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB NCCQ (UK) Revision Workshop Revision Workshop Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving hotel accommodation always ask for the Government Rate where this is available. Important Supplementary Information Anyone applying to attend this workshop needs to be aware that IHRIM and The Health Informatics Service are two separate organisations bound by Data Protection legislation which restrict the sharing of information on individuals between organisations. IHRIM and The Health Informatics Service have very distinct remits with regard to the NCCQ examination. IHRIM s responsibility as the awarding body is to manage all aspects of the examination itself, including delegate registrations for the actual exam. To assist in this, The Health Informatics Service does publicise the information but has no involvement in the administration of the exam and it is the responsibility of candidates to ensure they have registered and followed the necessary procedures to sit the exam. Crown Copyright www.this.nhs.uk 21

Workshop Neoplasm Workshop Introduction A 2 day course of classroom-based training developed by the NCS Clinical Coding Academies and delivered by The Health Informatics Service. The workshop offers specialty training to enable experienced clinical coders to further develop their knowledge and understanding of the processes and terminology associated with the classification of neoplasms, both diagnostically and procedurally. Attendance Criteria To benefit from this workshop, it is essential that participants have already completed a clinical coding foundation course using the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals. Learning Outcomes At the end of this workshop delegates will be able to: Accurately comply with national standards, rules, conventions and best practice pertaining to the coding of neoplastic specialties, including the classification of chemotherapy and radiotherapy procedures and the associated diagnostic information Understand the more complex areas of case note extraction associated with neoplasm coding, including definitions, terminology and the development of neoplasms Understand and apply coding principals to neoplasm case study scenarios Whilst there will be no formal assessment, delegates will work through a range of exercises, reinforcement activities and case study scenarios. Benefits to the Delegate and Employer Unique workshop, developed by the Clinical Coding Academies Project, to specifically meet the needs of clinical coders in the study and coding of neoplasm episodes to satisfy the requirements of Payment by Results Provision of an optimal learning environment Development of a greater understanding and knowledge about neoplasms, including their properties, anatomy and behaviour (including benign, in-situ, uncertain behaviour and primary and secondary neoplasms) Ability of understand and accurately code complex neoplasm case study scenarios, including the accurate classification of chemotherapy and radiotherapy procedures Access to a highly experienced and skilled NHS Classifications Service Approved Clinical Coding Trainer Opportunity to network with other experienced clinical coders Contributes towards studying for the National Clinical Coding Qualification (UK) Course Materials Delegate course folder, including a work book and several handouts NHS Classifications Service compliant ICD-10 and OPCS-4 answer book, including diagnostic and procedural rationales The Health Informatics Service Certificate of completion of the course 22 Clinical Coding Training and Audit

Reference Materials Each delegate must supply their own reference books for use during the course: World Health Organisation s International Statistical Classification of Disease and Related Health Problems Tenth Revision Volumes 1,2 (1992) and 3 (Reprinted with corrections and updates 2000, Geneva, WHO). NB: please be aware that the ICD-10 2nd Edition is not mandated for use within the NHS OPCS Classification of Surgical Operations and Procedures Fourth Revision, OPCS-4.6, Tabular List (Volume I) and Alphabetical Index (Volume II) OPCS-4.6 Chemotherapy Regimen List & Guidance Version 2.0 (April 2011) document Medical Dictionary Course Timings Tuition time is Day 1 is 09:00 16:00 & Day 2 is 09:00 15:30 Neoplasm Workshop Workshop However, please note that delegates are requested to arrive 15 minutes before 9:00 to ensure a prompt start and that the daily finishing times are only an indication, as each day will finish at an appropriate point within the schedule, to be compliant with learning needs. Registration Complete a Training Course Registration Form and submit to the Health Informatics Service: By email to: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Accommodation If you require overnight accommodation during the course you will need to arrange this separately. If reserving accommodation, always ask for the Government Rate where this is available. The Coding Solution Company Ltd www.this.nhs.uk 23

Clinical Coding Audit Clinical Coding Audit The underlying principles of the modernisation agenda of the NHS are to ensure the provision of first-class patient care, relying on high quality information exchange between healthcare professionals. Regular clinical coding audit will ensure that Trusts can have confidence in the accuracy and robustness of their coded data ensuring that it is fit for purpose, as any errors could adversely affect their income as well as clinical data quality. As an NCS Clinical Coding Academy we are committed to ensuring provision of the highest quality of coded clinical data audits, delivered by registered NHS Connecting for Health (NCH) approved auditors who have completed the Clinical Coding Auditor Programme (CCAP). Our auditors have a successful proven track record of high quality auditing, report writing and coding expertise, both within the NHS and the private sector, adhering to the clinical coding auditor s code of conduct. All of our auditors follow the clinical coding audit methodology version 4.0, using the four key measurement criteria in order to assess the quality of the coded data: accuracy (applying the three dimensions of coding), consistency, timeliness and completeness. The aim of clinical coding audit is to: Ensure adherence to the primary diagnosis definition Compliance with all coding rules and conventions HRG analysis to help support PbR Identify potential sources of error for example: - Source documentation e.g. poor quality case-notes and discharge summaries, conflicting documentation - Abstraction and code assignment errors e.g. incorrect code used, omission of relevant codes, over coding - Processing of codes e.g. number transposition, system constraints - Coding processes e.g. locally agreed policies which contravene national standards, lack of training Encourage and promote clinician validation of the coded data and interaction with coding teams Identify coding practices which need improving Make recommendations to improve the quality of the coded data and departmental processes 24 Clinical Coding Training and Audit

Clinical Coding Audit A typical audit package will consist of the completion of a pre-audit questionnaire to outline the organisational background, pre-audit meeting, the on-site audit (typically consisting of 200 FCE s over 3 days with 2 auditors on site), daily feedback sessions to discuss and agree any errors found, an exit meeting to discuss the findings and provide a brief overview of any recommendations, a draft report (which has been peer reviewed) for ratification, and a final report (copy of which will be submitted to NHS Connecting for Health). We deliver a variety of audits to organisations, typical examples of which are: Information Governance (compliant with relevant IG Toolkit requirements) Data Quality PCT Assurance Bespoke specialty audits e.g. mortality, cardiothoracic, orthopaedic or other specialty audits Clinical Coding Audit In addition to the programme of audit which we can provide, we can also help to mentor those members of the NHS who are new to the world of clinical coding audit, helping to assist with their first audits, along with advising on best practice and report writing. To discuss your audit requirements and for further information and prices, simply contact us at: jayne.lawson@this.nhs.uk or mary.jacklin@this.nhs.uk The Coding Solution Company Ltd www.this.nhs.uk 25

Apprentice Trainer Support Apprentice Trainer Support Upon successful completion of the Clinical Coding Trainer Programme (CCTP) an apprentice clinical coding trainer must undergo assessment by the an NCS Clinical Coding Academy TAP Assessor for promotion to approved experience status no less than 6 months and no later than 2 years from the end of the CCTP course. Since 1 April 2011 this assessment should be requested by means of completing the NCS Trainer Assessment Request form, available from the NCS, as a formal mechanism for requesting trainer assessments. Prior to this application for assessment the apprentice trainer must deliver a minimum of two clinical coding foundation courses (or one complete foundation course plus 18 days of other internal coding training delivery. Failure to undergo a promotion assessment within 2 years will result in the apprentice trainer having their approved status revoked. To support apprentice clinical coding trainers the Academy is able to offer the opportunity for co-delivery of foundation level training to enable the apprentice trainer to develop the competence and confidence required, and to build up the necessary experience (36 training days) for successful promotion to experienced status. Co-delivery will typically include: Assisting in the preparation of the training environment Assisting in the organisation of the training materials Observing two half day sessions Facilitating exercises and group work in four sessions to gain experience of working with delegates Delivering training in at least four sessions, covering two each of ICD-10 and OPCS-4 chapters. Verbal feedback will be provided to the apprentice at the end of each session and a written report on completion of the period of co-delivery. If you are an apprentice trainer seeking such an opportunity contact us at mary.jacklin@this.nhs.uk 26 Clinical Coding Training and Audit

Apprentice Trainer and TAP Re-Certicication Assessment There are now over 100 approved clinical coding trainers with privileged access to the NCS core suite of official training materials as the national standard versions mandated for use in the NHS. These trainers have completed the NCS programme and comply with a framework of requirements as set by them. This includes continued professional development which allows registration as an approved clinical coding trainer. Once a delegate has attended in full, and successfully completed, the Clinical Coding Trainer Programme, they are awarded a Certificate from the NCS confirming Approved Apprentice Clinical Coding Trainer status, which is valid for 2 years from the course end date. In addition, the delegate is awarded a Training Delivery Skills Certificate from the Training Foundation, which is valid for 3 years. An Apprentice Trainer must undergo assessment by a TAP certified trainer assessor for promotion to Approved Experienced status no less than 6 months and no later than 2 years from the end of the Clinical Coding Trainer Programme course, having delivered 2 full NCS approved Clinical Coding Foundation Courses. Failure to undergo a promotion assessment within 2 years will result in the Apprentice Trainer having their Approved status revoked. Experienced status will then be valid for 3 years from the date of the successful promotion assessment. In addition, an Experienced Trainer must undergo a Re-Certification Assessment 3 years from the date of receiving their original Training Delivery Skills Certificate from the Training Foundation. This certifies that a trainer s delivery skills remain at the appropriate level and can be undertaken by the THIS Clinical Coding Academy TAP certified trainer assessor. Failure to undergo Re-Certification Assessment within this timeframe will result in the Experienced Trainer having their Approved status revoked. THIS Clinical Coding Academy provides the opportunity for Clinical Coding Trainers, both Apprentice and Approved Experienced status, to be assessed against the TAP Training Delivery Skills criteria and profiles. Assessments can be carried out in our training delivery centre or on-site dependent upon individual preferences. Please note where assessments are to be carried out in the apprentice trainer s organisation a charge will be made to cover the Assessor s daily rate and travelling expenses. Apprentice Trainer and TAP Re-Certification Assessment The Coding Solution Company Ltd www.this.nhs.uk 27

Audit Report Assessments Audit Report Assessments Independent Auditors Since 1 April 2011 the assessment of annual audit reports produced by solely independent Approved Clinical Coding Auditors (and commercial company audit leads) will be carried out by Approved Clinical Coding Auditors employed within the NCS Clinical Coding Academies. However, Information Governance report assessments for progression to experienced auditor status will be undertaken by the NCS. The Clinical Coding Academies will use the same assessment criteria used by the NHS Classifications Service to mark NHS auditor reports in order for independent auditors to retain their Approved Auditor status, as applicable. Feedback will be provided where necessary. For any auditor whose report does not initially meet the audit report writing requirements, an action plan will be provided along with the opportunity to re-submit a report for marking by a given date. Beyond this, failure to meet the action plan will result in re-attendance of the Clinical Coding Auditor Programme (CCAP), or Auditor Refresher Workshop training as appropriate. Approved Auditor status for the individual will be withdrawn until successful completion of this additional training can be demonstrated. A charge of tbc plus VAT is payable for the initial marking of the audit report, and a further charge of tbc plus VAT for any re-submitted report following feedback. PRICES MISSING 28 Clinical Coding Training and Audit

Registration Terms & Conditions T&C s The Fees The quoted fees for courses and workshops include documentation, unless otherwise stated, refreshments at each course break and lunch. Cancellations A cancellation charge of 100% of the fee will be levied for all cancellations made 28 days or less before the course and cancellations within 40 days will be charged 50%. If you wish to make a cancellation please follow the instructions below: 1. Inform the Administration Officer immediately by telephone (01484 355406) 2. Post, fax or e-mail written confirmation of the cancellation, signed by the person who authorised the original registration form: E-Mail: mary.jacklin@this.nhs.uk or By post to: Clinical Coding Training Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB No charge will be made for a change of delegate, providing he / she complies with the course attendance criteria but for changes made shortly before a course we cannot guarantee that the delegate will receive the course documentation in time. Accommodation Delegates attending courses are responsible for their own overnight accommodation where this is required, travel arrangements and resulting costs. Delegates will be provided with a map and a list of accommodation in the area known to The Health Informatics Service. The Health Informatics Service takes no responsibility for any accommodation booked by delegates. Copyright The copyright of all course material and publicity material is invested in the Crown, except where stated and may not be reproduced in whole or in part, recorded, loaned, broadcast, stored in a retrieval system or displayed publicly without prior permission. www.this.nhs.uk 29

T&C s Registration Terms & Conditions Course Content 1. Course content will be as stated in the current The Health Informatics Service course details. Course content for other courses will be as described in published course publicity. The Health Informatics Service reserves the right to amend course content without notice. 2. Course content for on-site courses will normally be as described in the current The Health Informatics Service course details, except where otherwise agreed in writing with the client. Course Dates and Venues 1. The Health Informatics Service reserves the right to change any course dates as published in its schedule of courses. 2. The Health Informatics Service reserves the right to cancel an individual confirmed reservation by sending written notice to the client not less than five days prior to the start of a course. 3. If The Health Informatics Service is unable to start or complete a scheduled course because of illness or any other cause beyond its control, and where no notice is given, it shall attempt to rectify such situations but will not be liable for any consequential loss or expenses incurred by the client. 4. If The Health Informatics Service is obliged to change advertised course venues for reasons beyond its control, it shall provide as much notice as possible but will not be liable for any consequential loss or expenses incurred by the client. On-Site Courses The client is responsible for providing adequate training facilities, including refreshments, for on-site courses. Should a trainer or facilitator feel that requirements are not met (e.g. with regards to Health and Safety) The Health Informatics Service reserves the right to terminate an event and recover costs. High Quality Training Locations Nationwide The Health Informatics Service operates from numerous locations across the UK, each close to major communication routes. All training centres are equipped to a high standard, with large comfortable classrooms and relaxing break-out areas. Many of the training centres we use have on-site car parking. Our classrooms are equipped with large individual work spaces to both accommodate reference and course materials, supplemented by white boards and projectors. Lunch and refreshments are provided for all of our training courses and workshops. Data Protection Details of all client registrations are maintained on a database. These details may be used to advise our clients of other Health Informatics training products and services but are not made available to any other organisation for any purposes. If you do not wish your details to be held in this way please advise us. If you wish to see a copy of the details we hold about you as an individual these can be provided on request subject to verification of identity. 30 Clinical Coding Training and Audit

Delegate Code of Conduct As a delegate of any clinical coding course or workshop you will be expected to agree to comply with the following requirements: 1. To respect the Trainer has a contract with my organisation to help and develop my clinical coding skills. 2. To respect the Trainer s enthusiasm for the course contents and materials and to respond with enthusiasm. 3. To respect the Trainer s credentials. 4. To keep an open mind about the training methodology covered and to willingly participate for the duration of the course. 5. To return promptly from refreshment and lunch breaks at all times requested by the Trainer. 6. To respect and value all contributions from my fellow delegates. Delegate Code of Conduct 7. To act in a manner that will not cause offence or embarrassment to either fellow delegates, myself or the Trainer. 8. To discuss any controversial opinions I have about course content or training methodology with the Trainer in an appropriate manner outside the classroom environment to avoid disruption during course time. Failure to comply with any of the above requirements during the training course will result in the following action being taken: Step 1. The Trainer will refer you back to the above Delegate Code of Conduct signed at the start of the course and discuss and agree a way forward to resolve the situation outside the classroom environment. Step 2. If you continue to breach this agreement by behaving in a disruptive manner, the Trainer will contact your Line Manager, where applicable, and recommend your removal from the course at full cost to your organisation. Step 3. The Trainer will insist you leave the course immediately. Where applicable, The Health Informatics Service will send a written incident report to you or your Line Manager. www.this.nhs.uk 31

The Health Informatics Service Oak House Woodvale Road Brighouse West Yorkshire HD6 4AB Telephone: 01484 355420 E-mail: contact-us@this.nhs.uk www.this.nhs.uk The Health Informatics Service is Hosted by Calderdale and Huddersfield NHS Foundation Trust.