• I am an approved clinical coding auditor. Could you let me know what audit materials and support should be available to me and how I can access these?
• Do I receive a certificate or other proof I passed the Clinical Coding Auditor Programme (CCAP) and the Audit Refresher Course?
• Is there retrospective issue of certificates?
• At what point do I go on the register of approved clinical coding auditors?
• What do I need to do to maintain my status as a NHS-based approved auditor?
• How do I send in my audit report for assessment?
• I am an approved experienced NHS auditor what happens to the annual audit report once I have sent it in?
• What happens if?
  1. I do not meet the criteria to become an approved experienced auditor
  2. I do not meet the criteria to maintain my status as an approved experienced auditor
• How often is an auditor's approved auditor status reviewed?
• My anniversary date coincides with when I am on maternity leave. What can I do to ensure my approved auditor status is not withdrawn?
• I have not submitted an audit report for assessment for 2 years, but I have recently completed the Approved Auditor Refresher. Will this maintain my registration as an approved auditor?
• Can the audit report submitted by an NHS auditor for assessment purposes in order to maintain approved auditor registration annual registration be used for anything else?
• I have conducted an IG audit on an organisation so do I have to send the NCS the report?
• What do you do with the organisation's IG reports?
• I am an approved apprentice auditor. Do I have to attain experienced auditor status before I can carry out an IG audit?
• I am an NHS approved auditor and I have been asked to perform an IG audit at another Trust. Would this be considered an internal or an external audit?
• I am a lapsed auditor - I did the course but did not send in reports to maintain my registration for over a year. What do I do now?
• I did my audit report while working for a commercial company but now work for the NHS. What is my position?
• As a newly qualified auditor I am working as a second auditor. Am I able to submit an audit in which I was involved as second auditor in order to maintain my approved auditor status?
• I have successfully passed all of the aspects of the Clinical Coding Auditor Programme. What steps do I need to take to maintain approved auditor registration?
• I qualified as an auditor before 2010/11. What are the implications of the changes to qualification to become an auditor with the introduction of the CCAP?
• When do I have to take up the refresher course - three years from the date of my audit report mark or three years from my course attendance?
• When is the audit newsletter going out?
• Is there a change document available summarising the changes to the audit documents?
• I have given my permission for my auditor details to be published but my name is not included on the list of NHS Approved Clinical Coding Auditors on the website – why?
• I didn't receive the new audit methodology and documents - why?
• What are the criteria for completing the Clinical Coding Auditor Programme?
• Where can I find a report writing course?
• At our Trust we have local policies around the recording of certain conditions and procedures. How are these local policies treated for audit purposes?
• Are standards found in training materials but not published in the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals or Coding Clinic able to be used as evidence?
• What happens during audit if the Trust and Auditor cannot agree on a particular error found at audit?
• Can the NHS Classifications Service provide Approved Auditor Refresher Courses outside of their scheduled events?

I am an approved clinical coding auditor. Could you let me know what audit materials and support should be available to me and how I can access these?

All supporting and training materials are given out on successful completion of the audit courses. Other support materials are available on our website and include FAQ, the clinical coding auditor toolbox and useful links. The methodology and code of conduct is emailed to all registered NHS and independent auditors. Commercial audit companies distribute the documents to their teams.

Do I receive a certificate or other proof I passed the Clinical Coding Auditor Programme (CCAP) and the Audit Refresher Course?

From 2010/11 a certificate of auditor status is issued once the qualifying report has been marked. This will show whether an auditor has apprentice or experienced status. On successful completion of the annual audit report requirement to maintain approved auditor status the certificate will be dated and reissued to NHS based auditors.

An Auditor Refresher Workshop renewal certificate is issued on successful completion of the Auditor Refresher. The renewal date on this certificate specifically indicates when an auditor must attend their next Auditor Refresher Workshop, i.e. every 3 years.

Is there retrospective issue of certificates?

No there is no retrospective issue of certificates. The certificate process will be introduced in April 2011.

At what point do I go on the register of approved clinical coding auditors?

When you have successfully completed the Clinical Coding Auditor programme (CCAP) and the report from the course has been assessed and it meets the required criteria, and you have confirmed your permission for the NCS to pass on your details to third parties, you will be added to the register of approved clinical coding auditors. Newly qualified auditors are known as approved apprentice auditors. If you are an NHS-based auditor, your name will be placed on the approved list of NHS auditors on our website. If you are a non-NHS auditor, your name will be added to the list of approved non-NHS auditors which can be requested via datastandards@nhs.net

What do I need to do to maintain my status as a NHS-based approved auditor?

In order to maintain auditor registration auditors must submit one annual 200 FCE (minimum) audit report to the NHS Classifications Service (NCS) for assessment. The audit can be undertaken as a one-off 200 FCE audit, or a series of smaller audits totalling 200 FCEs, but for assessment purposes to maintain auditor registration the findings must be consolidated into one audit report.

The annual deadline or 'anniversary' date for an approved auditor to submit their clinical coding audit report is based on the date the auditor attended the clinical coding auditor workshop. For example if an auditor attended the Audit Workshop on 14 to 16 September, then their annual registration date is the 16 September, i.e. the last day of the workshop. An auditor should submit the report no sooner than 4 weeks before the anniversary date. It is an auditor's responsibility to send in the report they wish to submit for marking as part of their annual assessment requirement at the appropriate time. The NCS will NOT send out any reminders.

The report will then be assessed and if it meets the required criteria you will maintain your status.

How do I send in my audit report for assessment?

NHS based auditors can send their report electronically to datastandards@nhs.net. Individual NCS team members cannot accept the reports. We do not accept paper copies. The full assessment criteria process for non-NHS commercial company and independent auditors will be disseminated as appropriate. Further information regarding NHS and non-NHS auditor assessment has been published in the April 2011 Auditor Bulletin.

I am an approved experienced NHS auditor. What happens to the annual audit report once I have sent it in?

From receipt of the audit report at our helpdesk the reports are filed on our system to be assessed within 20 working days of receipt. From 2011-12 we will post a certificate to you confirming your status as an approved auditor along with the result, providing you meet the assessment criteria.

What happens if?

1. I do not meet the criteria to become an approved experienced auditor
2. I do not meet the criteria to maintain my status as an approved experienced auditor

In both instances 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.

How often is an auditor's approved auditor status reviewed?

Approved auditor status is reviewed annually and any approved auditor will retain their status as long as they have complied with the requirements outlined in the post audit process session of the Clinical Coding Audit Workshop.

My anniversary date coincides with when I am on maternity leave. What can I do to ensure my approved auditor status is not withdrawn?

Please email datastandards@nhs.net to confirm the date from which you will be taking maternity leave. We will then update the database to ensure that your auditor status is maintained during this period. You will need to contact datastandards@nhs.net to inform us when you are back from maternity leave. We will then be able to arrange your next report submission to continue your auditor registration.

I have not submitted an audit report for assessment for 2 years, but I have recently completed the Approved Auditor Refresher. Will this maintain my registration as an approved auditor?

No, completion of the Auditor Refresher Course does not replace the need to submit an annual audit report for assessment. Whilst it is anticipated that an approved auditor will be completing a number of audits / reports as part of their role, it is expected that approved auditors will submit one report annually to the NCS for assessment to maintain their registration and as evidence of continued professional development in this specialist field. This is in addition to the need to attend an Auditor Refresher every 3 years.

Can the audit report submitted by an NHS auditor for assessment purposes in order to maintain approved auditor registration annual registration be used for anything else?

Yes, this report can also be used to satisfy Information Governance requirements. When submitting a report to the Helpdesk, auditors are required to identify the purpose of the report, i.e. whether it requires assessment by the NCS in order to maintain auditor status, or whether it is for filing as the Trust's proof of adherence to the IG Toolkit, or for both of these purposes. If, for example, you want to use your organisation's IG report six months after submitting it to us for IG purposes you will then have to resend it ,stating this as the new purpose for marking. An auditor must send their report no sooner than four weeks before their anniversary date.

I have conducted an IG audit on an organisation so do I have to send the NCS the report?

Information Governance (IG) Requirement 8-505 stipulates that acute NHS Trusts need to complete a minimum 200 FCE audit every year (this can be undertaken as a one-off audit or a series of smaller audits, but must total a minimum of 200 FCEs) in order to satisfy this requirement. For IG purposes a Trust is required to submit the report(s) to the NCS as evidence this has been completed. Typically this is submitted by the auditor that undertakes the audit, but can be submitted by a Trust representative if preferred. As indicated in IG Requirement 8-514 for mental health Trusts the required number of FCEs that need to be audited per year is 50.

What do you do with the organisation's IG reports?

If you are submitting an IG audit report as an organisation's proof of compliance with IG Requirement 505, then this must be identified when you submit the report to the Helpdesk. These reports will be filed.

I am an approved apprentice auditor. Do I have to attain experienced auditor status before I can carry out an IG audit?

No, if you have successfully completed the Clinical Coding Auditor Programme you are fully trained in the use of the Clinical Coding Audit Methodology and therefore qualified to undertake an internal IG audit as either a second auditor or a lead auditor.

I am an NHS approved auditor and I have been asked to perform an IG audit at another Trust. Would this be considered an internal or an external audit?

All IG audits are classed as internal audits as they are commissioned by a Trust (even if the Trust you are undertaking the audit at is not your own Trust). An external audit is one that has been commissioned by an external organisation: for example a PbR Audit performed on behalf of the Audit Commission.

I am a lapsed auditor - I did the course but did not send in reports to maintain my registration for over a year. What do I do now?

Any lapsed auditors must re-attend the Clinical Coding Auditor Programme in full and at full cost. Details of joining criteria can be found on our website.

I did my audit report while working for a commercial company but now work for the NHS. What is my position?

Please email datastandards@nhs.net to confirm the date that you rejoined the NHS. We will then be able to advise you when your next report is required in order to continue your Approved Auditor status.

As a newly qualified auditor I am working as a second auditor. Am I able to submit an audit in which I was involved as second auditor in order to maintain my approved auditor status?

It does not matter whether you were lead or second auditor as long as you are the sole author of the report.

I have successfully passed all of the aspects of the Clinical Coding Auditor Programme. What steps do I need to take to maintain approved auditor registration?

Within 12 months of completing the CCAP the auditor must send one 200 FCE report for assessment (this can be undertaken as a one-off audit or a series of smaller audits, but must total a minimum of 200 FCEs). The annual deadline or 'anniversary' date for an approved auditor to submit their clinical coding audit report is based on the date the auditor attended the clinical coding auditor workshop.For example if an auditor attended the Audit Workshop on 14 to 16 September, then their annual registration date is the 16 September, i.e.the last day of the workshop. An auditor should submit their report to the NCS no sooner than 4 weeks before the anniversary date.

I qualified as an auditor before 2010/11. What are the implications of the changes to qualification to become an auditor with the introduction of the CCAP?

Auditors successfully completing the Clinical Coding Audit Programme (CCAP) 2010/11 will be listed as "approved". All existing registered auditors will be allowed to use the title "approved" if they attend an Approved Auditor Refresher Course within three years of successfully completing their initial audit training and have submitted an annual 200 FCE audit which fulfils the assessment criteria. As it is recognised that there are a limited number of places on the Auditor Refresher courses each year, an auditor will not lose their Approved Auditor status as long as they have actively been applying to attend a Workshop, and as long as they continue to submit their annual 200FCE reports in the interim.

When do I have to take up the refresher course - three years from the date of my audit report mark or three years from my course attendance?

Three years from your anniversary date, i.e. the last day of your original Clinical Coding Audit Workshop for your first auditor refresher, then the auditor refresher renewal date stated on your Auditor Workshop certificate every 3 years thereafter.

When is the audit newsletter going out?

The newsletter is issued twice a year. The last issue was in March2011. Any approved auditor wishing to receive the newsletter must keep us up-to-date with any changes to their contact details. http://www.connectingforhealth.nhs.uk/clinicalcoding/mailing-list.

Is there a change document available summarising the changes to the audit documents?

No there is no change document available for the methodology and code of conduct and any reissues supersede all past versions. These documents are issued when they are revised and must be adopted by all auditors.

I have given my permission for my auditor details to be published but my name is not included on the list of NHS Approved Clinical Coding Auditors on the website – why?

If your anniversary date has passed and you have not sent an annual audit report for assessment your registration will have lapsed and you will have been removed from the list of NHS registered auditors.

I didn't receive the new audit methodology and documents - why?

In the majority of cases when emails from NHS CFH do not appear to arrive at their destination it is not necessarily due to our system but rather for one of the following reasons:

1. The email address provided is incorrect. Our database relies on accurate information provided by the person filling in the form so please provide correct spelling and updated details if you move organisations or your email address changes.
2. Email bulletins can sometimes be considered as spam by an organisations spam filter. To increase the chances of receiving emails from us then please ask your IT department to add us as a safe sender particularly with regard to the email address nccs.bulletin@nhs.net. This should increase the chances of receiving the email.
3. Check your spam/junk email folder regularly in case the email has gone into that folder instead of your email inbox.
4. As a result of the above, the email system in your organisation would send a 'bounce' message back to our email bulletin system which will result in your email being removed from our mailing list. Again this is best resolved by you liaising with your IT department to adjust the email spam filters on your email account.
5. If your anniversary date has passed and you have not sent an annual audit report for assessment your registration will have lapsed and you will have been removed from the list of registered auditors and associated mailing lists.

What are the criteria for completing the Clinical Coding Auditor Programme?

There are a number of criteria that must be met before attending the Clinical Coding Audit Programme. http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/trainingaccred

Where can I find a report writing course?

If your Trust does not provide these courses as part of its employee continued professional development programme, alternative providers to consider are local colleges, commercial coding companies or on-line distance learning courses. A google search on the internet would also give results.

At our Trust we have local policies around the recording of certain conditions and procedures. How are these local policies treated for audit purposes?

Where local policies exist they must not contravene national standards. If they do so they will be recorded as an error at audit. If local policies do not contravene national standards and the local policy is not adhered to, it cannot be reported as an error, as coded clinical data is audited against national standards. However, failure to adhere to a local policy can and should be highlighted in the subsequent audit report.

Are standards found in training materials but not published in the ICD-10 and OPCS-4 Clinical Coding Instruction Manuals or Coding Clinic able to be used as evidence?

If after going through the normal coding process and checking ICD-10 and OPCS-4 index and tabular, Coding Clinic, Clinical Coding Instruction Manuals, and current OPCS-4 Chemotherapy Regimens and High Cost Drugs Clinical Coding Guidance documents, a code cannot be found – any selection beyond this point would be considered as 'judgmental'. For the purposes of clinical coding audit, training materials are not to be used as the basis for arbitration.

What happens during audit if the Trust and Auditor cannot agree on a particular error found at audit?

Where site representatives and auditors do not agree on an error, any discrepancies will be referred to the NHS Classifications Service audit query helpdesk via the Audit Query Mechanism. This mechanism should only be used where national standards have been contravened rather than issues of judgment where the views of the organisation and of the auditors differ. For further information please see the Guide to the Clinical Coding Audit Methodology (PDF, 144Kb)

Can the NHS Classifications Service provide Approved Auditor Refresher Courses outside of their scheduled events?

Unfortunately the NCS is unable to run bespoke Approved Auditor Refresher Courses over and above those available on the NCS training schedule.