The flow chart (PDF, 35Kb) describes the mechanism a clinical coder should follow when a query arises.

National Clinical Coding Query Mechanism

1. When a query arises follow these simple steps

2. Reference your classification volumes using the four step coding process, ICD-10 or OPCS-4 Clinical Coding Instruction Manual and Coding Clinic Collection

3. Perform internet research which may provide you with additional information. Discuss the query with your colleagues, line manager and speak to the appropriate health professional on site as they may be able to provide further information

4. Resolved

5. If a problem remains the query should be submitted via email (or post) to the National Clinical Classifications Helpdesk using the downloadable ICD-10 Clinical finding coding query form or the OPCS-4 Interventional clinical coding query form and providing a copy of anonymised supporting information

Fully anonymised supporting information is essential to providing a response suited to the particular circumstances of the query. Without adequate information there is a risk that an inappropriate code may be suggested or guidance offered which is not strictly accurate for the specific case. Without this information the query cannot be progressed and will be returned to the originator

6. You will receive a unique log number from the helpdesk first line support and your query will then be sent on to the relevant specialist

7. Queries pertaining to coding conventions and guidance for ICD-10 and OPCS-4 are assigned to the NHS Classification Service and a classification specialist deals with your query

8. Research is undertaken and resolution is formulated in accordance with national clinical coding standards

9. We are unable to deal with queries relating to HRG / Payment by Results (PbR) tariff and you are recommended to forward your query to the NHS Information Centre or Department of Health PbR team

10. The resolution is then quality checked in a rigorous assurance process. Once this process has been satisfied the decision will be sent to you

11. Unresolved

12. Some queries may require further specialist or clinical input or relate to policy or principles that have implications for coding standards. In this scenario the query will be researched further and/or consultation with other experts and then reviewed by the UK Coding Review Panel (UK CRP). If national guidance or clarification to a standard is required this will be published in the Coding Clinic, and included in the next release of the Clinical Coding Instruction manual

13. The UKCRP provides a collaborative focus to review and advice on coding and classifications issues affecting England, Northern Ireland, Wales and Scotland and quality assures proposed guidance. It includes representation from the clinical coding community, home countries, Department of Health, the NHS Information Centre (IC), Hospital Episode Statistics (HES) and clinical involvement

14. As well as the query being published in the Coding Clinic, if necessary, you will receive written confirmation of the resolution.