Clinical coding

Question 1

What is clinical coding?

Answer 1

• Clinical Coding is the translation of medical terminology, as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention into a coded format which is nationally & internationally recognised.

Question 2

Why use clinical coding?

Answer 2

Better coding and data capture –> better information –> better, faster care

Question 3

Name some uses of clinical coding?

Answer 3

1. Epidemiological studes
2. Service planning
3. Payment by results

Question 4

Name 3 types of clinical coding systems?

Answer 4

1, ICD-10 (international classification of diseases)

2. OPCS-4 (Classification of Interventions and Procedures)
3. SNOMED-CT (Systematized nomenclature of medicine)

Question 5

List pros and cons of ICD10 and OPCS

Answer 5

Pro- well known, trained staff

Con- Single hierarchical, difficult to amend/change

Question 6

List pros and cons of SNOMED-CT

Answer 6

Pro- Multiple hierarchy, easily appended or updated

Con- Very large and complex