Cwray

Chris Wray

This user is a native speaker of the English language.

A clinical coder is a person who simplifies the details of a patients stay in a medical facility so that this information may be manipulated statistically.

In the UK, this coding is performed on procedures and diagnoses separately. For the purposes of clinical coding a procedure is normally any form of medical intervention (from taking a blood sample to open surgery) and the diagnosis is deemed to be the medical description of the problem that the procedure is used to treat.

For example. (and this is going to be a straight forward example)

A patient is admitted due to passing blood per rectum. A colonoscopy is performed and bleeding haemorrhoids are discovered.

For this example the diagnosis would be bleeding haemorrhoids and the procedure would be the colonoscopy.

Unfortunately, not many multi-day admissions are as straight forward as that example, so there is a prefessional definition of the "main diagnosis" which can be used to help determine what to code. This definition is as follows.

Main Diagnosis

The condition treated or investigated during the relevant episode of healthcare.

Where there is no definitive diagnisis made the main symptom, abnormal finding or problem should be selected as the main condition

As has already been mentioned, the diagnoses and procedures are coded separately. The codes produced are similar in structure for both.

For the diagnosis side of coding (in the UK) we use a system known as the "International Statistical Classification of Diseases and Health Related Problems" which is presently on its Tenth Revision. This is commonly abbreviated to ICD 10 and these codes are often shown in the top right hand corner of medi-wiki pages.

The procedure codes were originally issued by the "Office of Population Censuses and Surveys" in 1990. We are presently using "Classification of Interventions and Procedures Version 4.4" which is commonly referred to as OPCS 4.4. Unfortunately there is no online version of this available at present so there are no links available on any of the Wikipedia pages.

Once these codes have been assigned, they have traditionally been used predominantly for epidemiological purposes in the UK. Although in recent years the use has gradually been altered so that it is also used for the generation of finances based upon the treatment that has been performed.

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.

F. Scott Fitzgerald (1896 - 1940), "The Crack-Up" (1936)

Well here we go... Into the world of freedom of knowledge, but with censorship;~}

I am a clinical coder and I often use Wikipedia (predominantly the medical side) to help me to better understand the information that I am working with.

I have also registered to enable me to occasionally edit pages as sometimes the ICD10 codes which are listed are incorrect or (more commonly) missing.