Change Request
 

NHS Connecting for Health

NHS Data Model and Dictionary Service

Reference: Change Request 1040
Version No:1.0
Subject:Update of OPCS Classification of Interventions and Procedures
Effective Date:1 April 2009
Reason for Change:Change to data standards to ensure consistent references to OPCS Classification of Interventions and Procedures (OPCS-4).
Publication Date:24 December 2008

Background:

The NHS Data Model and Dictionary has been revised to ensure consistent references to OPCS Classification of Interventions and Procedures (OPCS-4). In addition the OPCS Classification of Interventions and Procedures contextual overview has been updated to detail the release cycle.

Descriptions for OPCS-4 codes in the following definitions have been updated as recommended by the NHS Classifications Service, NHS Connecting for Health:

Summary of changes:

Supporting Information
METADATA FILES   Changed Description
OPCS CLASSIFICATION OF INTERVENTIONS AND PROCEDURES   Changed Description, Aliases
PUBLICATION INFORMATION CONTACT DETAILS   Changed Description
READ CODED CLINICAL TERMS   Changed Description
SECURITY ISSUES AND PATIENT CONFIDENTIALITY   Changed Description
 
Class Definitions
INTERVENTION CLASSIFICATION ASSOCIATION   Changed Description
OPERATIVE PROCEDURE   Changed Description
 
Attribute Definitions
ANATOMICAL EXAMINATION SITE   Changed Description
CLINICAL CLASSIFICATION CODE   Changed Description
PATIENT PROCEDURE IMPLANT INDICATION   Changed Description
 
Data Elements
ADMISSION INTENDED PROCEDURE   Changed Description
ADMITTED PATIENT NHS ADMISSIONS   Changed Description
ADMITTED PATIENT NON-NHS ADMISSIONS   Changed Description
DIAGNOSTIC TEST (ENDOSCOPY)   Changed Description
DIAGNOSTIC TEST (ENDOSCOPY CENSUS)   Changed Description
DIAGNOSTIC TEST (IMAGING)   Changed Description
DIAGNOSTIC TEST (IMAGING CENSUS)   Changed Description
DIAGNOSTIC TEST (PATHOLOGY CENSUS)   Changed Description
DIAGNOSTIC TEST (PHYSIOLOGICAL MEASUREMENT)   Changed Description
DIAGNOSTIC TEST (PHYSIOLOGICAL MEASUREMENT CENSUS)   Changed Description
HIGH COST DRUGS (OPCS)   Changed Description
HRG DOMINANT GROUPING VARIABLE-PROCEDURE   Changed Description
PRIMARY OPERATION (OPCS-4)   Changed Description
PRIMARY PROCEDURE (OPCS)   Changed Description
PROCEDURE CODING   Changed Description
PROCEDURE CODING (DIABETES RELEVANT OPCS-4)   Changed Description
PROCEDURE SCHEME IN USE   Changed Description
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS)   Changed Description
SARCOMA TUMOUR SITE   Changed Description
 

Date:24 December 2008
Sponsor:Paul Jones, Ken Lunn, Technology Office, NHS Connecting for Health

Note: New text is shown with a blue background. Deleted text is crossed out. Within the Diagrams deleted classes and relationships are red, changed items are blue and new items are green.

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METADATA FILES

Change to Supporting Information: Changed Description

Files Available
  • Metadata files are used by the NHS to validate data. The files facilitate data consistency and quality. The files are:
    • Diagnosis (ICD-10)
    • Operation (OPCS-4) Fourth Revision Consolidated Version
    • NHS Postcode Directory
    • Frozen Postcode Directory
    • Country Pseudo Postcodes.
  • The ICD-10 file is issued by NHS Connecting for Health, from whom a specification is available. It is intended to reissue this file in line with the ICD-10 updates.

  • The Operation metadata file is also issued by NHS Connecting for Health on request. No update of this file is currently envisaged.

  • The Operation metadata file and specification is issued by the NHS Classifications Service of NHS Connecting for Health to support implementation of new releases; see Contact Details.

  • The full and reduced versions of the NHS Postcode Directory are issued every quarter by the Organisation Data Service. Named recipients both inside the NHS and other recipients licensed to use this data in support of the NHS are able to access it through the online distribution service, TRUD (Terminology Reference Data Update Distribution Service) and through the Organisation Data Service pages on NHSnet; see Contact Details.

  • A full description of the NHS Postcode Directory and the Organisation Data Service reduced postcode data files, can be found by browsing the Office for National Statistics Data section of the Organisation Data Service pages on NHSnet at http://nww.connectingforhealth.nhs.uk/ods/downloads/officenatstats/ (NHS Postcode Directory) and http://nww.connectingforhealth.nhs.uk/ods/downloads/postcode/ (reduced files). The same descriptions can also be accessed via TRUD (Terminology Reference Data Update Distribution Service). 

  • Any area within the NHS taking advantage of the supply of metadata by the Office for National Statistics will be expected to abide by any rules and conditions imposed by the Office for National Statistics Section supplying the metadata.

  • Any area within the NHS taking advantage of the supply of metadata by the Office for National Statistics will be expected to abide by any rules and conditions imposed by the Office for National Statistics Section supplying the metadata.

    Format of Metadata Files
Media
  • NHS Connecting for Health Metadata files are normally supplied on disk. Potential users should contact the NHS Information Authority Coding and Classification Help Desk on 0121 333 0420 (direct line).

    Format of Metadata Files
  • The following pages give the record layouts and data content for Country Pseudo Postcode metadata files.

  • The following pages give the record layouts and data content for the Operation and Country Pseudo Postcode metadata files.

    Operation File Data Content
  • This file consists of about 7,000 records, one record for each operation (OPCS-4) Fourth Revision Consolidated Version used in the Hospital Episode Statistics processing system. The records are in operation code order. Each record also contains editing parameters used in validation.

    OPERATION FILE RECORD LAYOUT

    Start PositionSizeOccursField Description
    111 selection indicators
    121 operation prefix
    134 operation code
    178 filler
    2555 operation name (3 digit)
    805 filler
    8560 operation name (4 digit)
    14543 filler
    1881 sex (absolute)
    1893 filler
    1921 sex (scrutiny)
    1931 filler
    1942 status of operation
    19623 filler
    219110method of delivery
    22924 filler

    OPERATION FILE FIELD CONTENTS

    FieldContent
    Operation Prefixspace
    Operation Code4 chars, 1 alphanumeric + 3 numeric
    Sex (absolute)space = accept any sex code
    1 = males not accepted
    2 = females not accepted
    1 = males not accepted
    2 = females not accepted
    Sex (scrutiny)space = accept any sex code
    1 = males not accepted
    2 = females not accepted
    NB The following relate to primary operation only
    Status of Operationif status not = 01, reject for scrutiny
    Method of Delivery10 one character codes representing the DELMETH code values 0 - 9. Check character position corresponding to DELMETH code value

    space = no check required
    1 = reject for scrutiny
      
Country Pseudo Postcode File Data Content
  • This file contains about 130 records. The usual country of residence for short term overseas visitors is derived from the country pseudo postcode. The codes are  available in electronic format on the NHS Postcode Directory ("Gridlink version").

    For the Organisation Data Service contact details, see Contact Details.

  • The expanded area code field contains the country of birth code in characters 1-4 (a repeat of the characters 3-6 in the pseudo postcode). The remainder of the expanded area code is blank except for codes 993C (UK nos) and 993V (no fixed abode) where characters 5-7 are 9space9.

    COUNTRY PSEUDO FILE RECORD LAYOUT

    Start PosSizeData TypeField Description
    111Xselection indicators
    126X6 digit postcode (POSTSIX)
    181A7th digit
    196Xfiller
    2550Xname of country
    755Xfiller
    8019Xarea details
    99154Xfiller

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OPCS CLASSIFICATION OF INTERVENTIONS AND PROCEDURES

Change to Supporting Information: Changed Description, Aliases

  1. The classification of Surgical Operations and Procedures was originally issued by the Office of Population Censuses and Surveys (OPCS). The 4th revision was first implemented in hospital information systems in 1987. This was subject to a significant number of amendments and a consolidated version was reproduced in 1990 with future updates to reflect on-going maintenance.

  2. The classification of interventions and procedures (OPCS-4.2) was substantially enhanced and a new version implemented in 2006 (OPCS-4.3) with a commitment to undertake annual review and potential update. This will be continued until further notice.
  3. From OPCS version 4.3 onwards, the classification comprises a list of alphanumeric codes with mainly anatomically based chapters, most of which relate to the whole or part of a system of the body. Each is designated alphabetically e.g. Chapter A covers the nervous system and Chapter K the heart. The alphabetic character for each chapter forms the leading digit of the 3 and 4 digit codes within it. Chapters are based on body systems with specific operations being listed for individual organs.

  4. There are instances where an existing category needs extension. In such cases, and dependent on the chapter capacity, an extended category is added within the Tabular List chapter. These categories are referred to as principal category or extended category and identified by an accompanying note to ease navigation.

  5. Chapters that have reached capacity are then extended using alphanumeric categories which are assigned using the free alpha O. This has occurred within three chapters (Chapters L, W and Z). Codes created in this way still form part of an existing chapter even though they have a different alpha prefix to the rest of that chapter. Such new codes will, therefore, logically sit at the end of the body system chapter and are readily identified within the alphabetical index. There is an additional (Chapter X) for operations on multiple systems using miscellaneous procedures.

  6. The list of High Cost Drugs can be found in the Alphabetical Index. A separate detailed listing of common chemotherapy regimens used in the treatment of neoplasms is provided on the website at Chemotherapy Regimens for OPCS-4.4.

  7. The classification is published in two volumes. The Tabular List and Alphabetical Index are available from The Stationary office.

Introduction

The OPCS Classification of Interventions and Procedures (OPCS-4) is a Fundamental Information Standard.  The classification is used by Health Care Providers and Strategic Health Authorities.

 OPCS-4 is used to support operational and strategic planning, resource utilisation, performance management, reimbursement, research and epidemiology.  It is used by NHS suppliers to build/update software to support NHS business functions and interoperability.

The OPCS-4 is subject to annual review and potential update to ensure that modern clinical practice is represented appropriately.  This will be continued until further notice as shown below:

YearVersion of OPCS-4*
Up to 31 March 2006OPCS-4.2
01-Apr-2006 – 31-Mar-2007OPCS-4.3
01-Apr-2007 – 31-Mar-2008
01-Apr-2008 – 31-Mar-2009
OPCS-4.4
01-Apr-2009 – until further notificationOPCS-4.5


*Tables of Coding Equivalences are issued for mapping back to previous versions found at https://www.uktcregistration.nss.cfh.nhs.uk/trud/

The NHS Data Model and Dictionary contains a number of data collections that require OPCS-4 codes, such as Central Returns and Commissioning Data Sets.  All data collections should use the latest version of the  OPCS-4 classification as specified in the table above.

Background

The classification of Surgical Operations and Procedures was originally issued by the Office of Population Censuses and Surveys (OPCS). The 4th revision was first implemented in hospital information systems in 1987. This was subject to a significant number of amendments and a consolidated version was reproduced in 1990.

The OPCS Classification of Surgical Operations and Procedures (OPCS-4.2) was substantially enhanced to ensure that modern clinical practice was represented appropriately within the classification and a new version was implemented in 2006 titled OPCS Classification of Interventions and Procedures (OPCS-4.3) with a commitment to undertake annual review and potential update. The classification comprises a list of alphanumeric codes with mainly anatomically based chapters, most of which relate to the whole or part of a body system. Each chapter is designated alphabetically e.g. Chapter A covers the nervous system and Chapter K is assigned to the heart. The alphabetic character for each chapter forms the prefix of the 3 and 4 digit codes within it. The strict link between chapters and body systems with specific procedures being listed for individual organs was breached in OPCS-4.3 because of limited capacity.

There are instances where an existing category needs extension because all the available codes have been allocated. In such cases an extended category is created within the Tabular List chapter. These categories are referred to as principal category or extended category and identified by an accompanying note to ease navigation.

Chapters that have reached capacity are extended using alphanumeric categories which are assigned using the free alpha O. This has occurred within three chapters (Chapters L, W and Z). Codes created in this way still form part of an existing chapter even though they have a different alpha prefix to the rest of that chapter. Such new codes will, therefore, logically sit at the end of the body system chapter and are readily identified within the alphabetical index. There is an additional chapter (Chapter X) for operations on multiple systems using miscellaneous procedures.

The classification is published in two volumes. The Tabular List and Alphabetical Index are available from The Stationary office at www.tsoshop.co.uk

OPCS-4 Requests Portal

The OPCS-4 Requests Portal allows stakeholders to submit change requests to the NHS Classification Service all year round. A cut-off date is necessary to support the annual review of requests and business case to proceed with an update to the classification.

More information about this classification and access to the OPCS-4 Requests Portal can be found at:
http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/codingstandards/opcs4/44submissions

High Cost Drugs and Chemotherapy Regimens

The listings of High Cost Drugs and Chemotherapy Regimens which are mapped to OPCS-4 codes are provided as look-up tables downloadable either from:

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OPCS CLASSIFICATION OF INTERVENTIONS AND PROCEDURES

Change to Supporting Information: Changed Description, Aliases


PUBLICATION INFORMATION CONTACT DETAILS

Change to Supporting Information: Changed Description

CONTACT DETAILS

  1. General Enquiries about the NHS Data Model and Dictionary:

    NHS Data Model and Dictionary Service
    NHS Connecting for Health
    Princes Exchange
    Princes Square
    Leeds
    LS1 4HY

    Email: datastandards@nhs.net

    NHS Data Model and Dictionary Service Website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/datamodeldictionary

  2. The NHS Information Standards Board:

    The NHS Information Standards Board
    Princes Exchange 
    Princes Square
    Leeds
    LS1 4HY

    Internet: http://www.isb.nhs.uk/

  3. Hospital Episode Statistics (HES):

    Website: HES online

    Queries: HES queries

  4. Clinical Coding general enquiries:

    International Classification of Diseases (ICD-10)
    Classification of Surgical Operations and Procedures Fourth Revision Consolidated Version (OPCS-4);
    Clinical Terms (The Read Codes);
    SNOMED CT® (Systematised Nomenclature of Medicine Clinical Terms)

    For all general enquiries, contact:

    NHS Connecting for Health
    Data Standards and Products Help Desk
    E-mail: datastandards@nhs.net

    • Electronic copies of International Classification of Diseases (ICD-10) Volumes 1, 2 and 3
      • The ICD-10 metadata file and its specification;
      • The ICD-10 Codes and Titles (on diskette);
      • The ICD-10 Tables of Equivalence (on diskette);
    • The Alphabetical Index of Classification of Surgical Operations and Procedures (Fourth Revision Consolidated Version (OPCS-4) in hard copy;
      • Electronic format of Index and Tabular List of OPCS-4;
      • OPCS-4 metadata file and its specification;
    • Clinical Terms (The Read Codes) and SNOMED CT® (Systematised Nomenclature of Medicine Clinical Terms) are released to licensees every six months (March and September) via the Terminology Reference Data Update Distribution Service (TRUD).

      Information on the Terminology Reference Data Update Distribution Service (TRUD) can be found at: https://www.uktcregistration.nss.cfh.nhs.uk/trud/

      Hard copy versions of ICD-10 and the Tabular List of OPCS-4 are available from The Stationery Office (formerly HMSO).

  5. Clinical Coding general enquiries:

    International Classification of Diseases (ICD-10);
    OPCS-4 Classification of Interventions and Procedures;
    Clinical Terms (The Read Codes);
    SNOMED CT (Systematised Nomenclature of Medicine Clinical Terms)

    For all general enquiries, contact:

    NHS Connecting for Health
    Data Standards and Products Help Desk
    E-mail: datastandards@nhs.net
    Website: http://www.connectingforhealth.nhs.uk/systemsandservices/data/clinicalcoding/

    • Electronic copies of International Classification of Diseases (ICD-10) Volumes 1, 2 and 3
      • The ICD-10 metadata file and its specification;
      • The ICD-10 Codes and Titles (on diskette);
      • The ICD-10 Tables of Equivalence (on diskette);
    • OPCS-4 Classification of Interventions and Procedures;
      • OPCS-4 Codes and Titles;
      • OPCS-4 metadata file;
      • OPCS-4 Tables of Coding Equivalence;
      • Electronic format of Index and Tabular List of OPCS-4;
    • Clinical Terms (The Read Codes) and SNOMED CT® (Systematised Nomenclature of Medicine Clinical Terms) are released to licensees every six months (March and September) via the Terminology Reference Data Update Distribution Service (TRUD).

      Information on the Terminology Reference Data Update Distribution Service (TRUD) can be found at: https://www.uktcregistration.nss.cfh.nhs.uk/trud/

      Hard copy versions of ICD-10 and the Tabular List of OPCS-4 are available from The Stationery Office (formerly HMSO).

  6. Organisation Data Service Queries:

    Organisation Data Service
    Hexagon House
    Pynes Hill
    Rydon Lane
    Exeter
    Devon EX2 5SE

    exeter.helpdesk@nhs.net
    Tel: 01392 251 289

    Link ODS Organisation Data Service website pages:

    Information on the Terminology Reference Data Update Distribution Service can be found at: https://www.uktcregistration.nss.cfh.nhs.uk/trud/

  7. Postcodes:

    Postcode and Geographic Area Queries
    All Fields Postcode Directory
    Areas of Residence Classification
    NHS Organisation Manual
    1991 Frozen Postcode File
    Communal Establishment File

    Office for National Statistics Geography Customer Services Unit
    Office for National Statistics
    Segensworth Road
    Titchfield
    Fareham
    Hants
    PO15 5RR

    1991 Frozen Postcode File
    Communal Establishment File

    Tel: 01329 813243 or 813477
    Fax: 01329 813383
    e-mail: ons.geography@ons.gov.uk
    Internet: http://www.statistics.gov.uk

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READ CODED CLINICAL TERMS

Change to Supporting Information: Changed Description

  1. The Read Coded Clinical Terms are a comprehensive computerised coded thesaurus for use by clinicians. They are available in three main formats, known as Version 3, Version 2 and the 4-Byte sets, and are designed for use in the electronic health care record. Version 3 of the Read Codes is a "Superset" of the earlier versions as it contains all codes and terms from Version 2 and the 4-Byte set.

  2. Read Coded Clinical Terms may be used for coding within local systems but are not acceptable directly for coding Hospital Episode Statistics which are extracted from Admitted Patient Care Commissioning Data Set. Version 3 and Version 2 of the Read Codes both, however, contain mapping tables which can be used to generate ICD-10 and OPCS-4 codes.

  3. Read Coded Clinical Terms may be used for coding within local systems but are not acceptable directly for coding Hospital Episode Statistics which are extracted from Admitted Patient Care Commissioning Data Set. Version 3 and Version 2 of the Read Codes both, however, contain mapping tables which can be used to generate ICD-10 and OPCS-4 codes.

  4. For further information; see Contact Details.

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SECURITY ISSUES AND PATIENT CONFIDENTIALITY

Change to Supporting Information: Changed Description

SECURITY ISSUES AND PATIENT CONFIDENTIALITY

  • A. Removal of name and address where the NHS Number is present
  • From 1 April 1999, PATIENT NAME and PATIENT USUAL ADDRESS (not POSTCODE OF USUAL ADDRESS) must be removed from all Commissioning Data Sets where a valid NHS NUMBER is present. This applies to all nationally defined Commissioning Data Set data and any additional locally agreed flows from service providers to commissioning bodies.

  • A valid NHS NUMBER is one that has passed the check digit calculation on entry into the source system. If an NHS NUMBER is not valid (i.e. does not conform with the check digit algorithm) then PATIENT NAMES and PATIENT USUAL ADDRESSES should not be removed, as the reliability of the NHS NUMBER will not be known.

  • The NHS NUMBER STATUS INDICATOR is a mandatory part of the Commissioning Data Set. PATIENT NAME and PATIENT USUAL ADDRESS should be removed when a valid NHS NUMBER is present, even if the NHS NUMBER STATUS INDICATOR does not have a status of 01, Number present and verified.

    B. Marital Status
  • Following the recommendations of the Data Protection Registrar, Providers should not record MARITAL STATUS in any CDS TYPE, except in respect of the psychiatric specialities in the Admitted Patient Care CDS Types, where it will continue to be recorded.

    C. Sensitive data
  • The Human Fertilisation and Embryology Act 1990 as amended by the Human Fertilisation and Embryology (Disclosure of Information) Act 1992 imposes statutory restrictions on the disclosure of information about identifiable individuals in connection with certain infertility treatments. A list of the relevant codes is given in Table 1. In these cases the NHS NUMBER, LOCAL PATIENT IDENTIFIER, PATIENT NAMES, POSTCODE OF USUAL ADDRESS and BIRTH DATE should be omitted from the CDS Types.

  • Other statutory restrictions on the disclosure of PATIENT information do not prohibit the disclosure to individuals involved with the treatment and prevention of certain specific diseases (HIV/AIDS and venereal diseases) in the population.

    TABLE 1: TREATMENTS PROVIDED UNDER THE LICENCE OF THE HUMAN FERTILISATION AND EMBRYOLOGY AUTHORITY

    DescriptionOPCS-4ICD-10
    Standard In Vitro Fertilisation (IVF)Q13.-1 Introduction of gamete into uterine cavity, or
    Q38.3 Endoscopic intrafallopian transfer of gamete
    Z31.2 In vitro fertilization
    In Vitro Fertilisation (IVF) with donor spermQ13.- 1 Introduction of gamete into uterine cavity, or
    Q38.3 Endoscopic intrafallopian transfer of gamete
    Z31.2 In vitro fertilization
    In Vitro Fertilisation (IVF) with donor eggsQ13.-1 Introduction of gamete into uterine cavity, or
    Q38.3 Endoscopic intrafallopian transfer of gamete
    Z31.2 In vitro fertilization
    Donor insemination (DI)Q13.3 Intrauterine artificial insemination, or
    Q13.2 Intracervical artificial insemination
    Z31.1 Artificial insemination
    Gamete intrafallopian transfer (GIFT) with donor spermQ38.3 Endoscopic intrafallopian transfer of gameteZ31.3 Other assisted fertilization methods
    Gamete intrafallopian transfer (GIFT) with donor eggsQ38.3 Endoscopic intrafallopian transfer of gameteZ31.3Other assisted fertilization methods
    Intracytoplasmic sperm injection (ICSI)  
    Sub-zonal insemination (SUZI)  
    Zygote intrafallopian transfer (ZIFT)Q38.3 Endoscopic intrafallopian transfer of gameteZ31.2 In vitro fertilization
    Partial Zona Dissection (PZD)  
    Zona drilling  
    Hamster- egg penetration test  
    Assisted hatching  
    Pre-implantation Genetic Diagnosis (PGD)  
    Storage of sperm  
    Storage of embryos  
    Use and storage of testicular tissue  
    Transport/satellite In Vitro Fertilisation (IVF) / Intracytoplasmic sperm injection (ICSI)  
    Embryo donation Z31.8 Other procreative management
    Research  

    1.- means all fourth characters of this rubric should be included.

  • Other statutory restrictions on the disclosure of PATIENT information do not prohibit the disclosure to individuals involved with the treatment and prevention of certain specific diseases (HIV/AIDS and venereal diseases) in the population.

    TABLE 1: TREATMENTS PROVIDED UNDER THE LICENCE OF THE HUMAN FERTILISATION AND EMBRYOLOGY AUTHORITY

    DescriptionOPCS-4*ICD-10
    Standard In Vitro Fertilisation (IVF)Q13.-1 Introduction of gamete into uterine cavity, or
    Q38.3 Endoscopic intrafallopian transfer of gamete
    Z31.2 In vitro fertilization
    In Vitro Fertilisation (IVF) with donor spermQ13.- 1 Introduction of gamete into uterine cavity, or
    Q38.3 Endoscopic intrafallopian transfer of gamete
    Z31.2 In vitro fertilization
    In Vitro Fertilisation (IVF) with donor eggsQ13.-1 Introduction of gamete into uterine cavity, or
    Q38.3 Endoscopic intrafallopian transfer of gamete
    Z31.2 In vitro fertilization
    Donor insemination (DI)Q13.3 Intrauterine artificial insemination, or
    Q13.2 Intracervical artificial insemination
    Z31.1 Artificial insemination
    Gamete intrafallopian transfer (GIFT) with donor spermQ38.3 Endoscopic intrafallopian transfer of gameteZ31.3 Other assisted fertilization methods
    Gamete intrafallopian transfer (GIFT) with donor eggsQ38.3 Endoscopic intrafallopian transfer of gameteZ31.3Other assisted fertilization methods
    Intracytoplasmic sperm injection (ICSI)  
    Sub-zonal insemination (SUZI)  
    Zygote intrafallopian transfer (ZIFT)Q38.3 Endoscopic intrafallopian transfer of gameteZ31.2 In vitro fertilization
    Partial Zona Dissection (PZD)  
    Zona drilling  
    Hamster- egg penetration test  
    Assisted hatching  
    Pre-implantation Genetic Diagnosis (PGD)  
    Storage of sperm  
    Storage of embryos  
    Use and storage of testicular tissue  
    Transport/satellite In Vitro Fertilisation (IVF) / Intracytoplasmic sperm injection (ICSI)  
    Embryo donation Z31.8 Other procreative management
    Research  

    1.- means all fourth characters of this rubric should be included.
    * see OPCS Classification of Interventions and Procedures

  • All records containing patient identifiable information, other than those covered by the Human Fertilisation & Embryology Acts, as outlined in the Table above, should be treated as sensitive. Organisations may continue to exchange records containing NHS NUMBER, POSTCODE OF USUAL ADDRESS and BIRTH DATE in these cases, but receiving organisations must ensure that only those staff with legitimate need have access to this information, e.g. public health departments, and strictly on a need to know basis. No-one should have unrestricted access unless fully justified in accordance with the principles of the Caldicott Committee Report.

  • Where PATIENT level data is required for other purposes within an organisation, it should be anonymised/aggregated prior to disclosure by someone with legitimate access. If this is not practicable, local protocols defining which CDS TYPES are particularly sensitive (including, but not necessarily restricted to HIV/AIDS and venereal disease) agreed by the organisation Caldicott Guardian, should be put in place and identifiers stripped from these records.

  • Your Caldicott Guardian will be able to advise you further on all issues relating to patient confidentiality.

  • Where appropriate, further information about confidentiality is contained within the notes for individual data items.

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INTERVENTION CLASSIFICATION ASSOCIATION

Change to Class: Changed Description

This identifies the clinical classification code which may be applied to a CLINICAL INTERVENTION. For example OPCS-4 operative procedure code. For example OPCS-4 operative procedure code.

 

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OPERATIVE PROCEDURE

Change to Class: Changed Description

A subtype of CLINICAL CLASSIFICATION.

A unique code identifying an operation which can be performed on a PATIENT. The coding structure is provided by the Office for National Statistics and defined in the OPCS Operations Classification, 4th Revision.

 

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ANATOMICAL EXAMINATION SITE

Change to Attribute: Changed Description

A classification of the part of the body that is the subject of an Imaging Or Radiodiagnostic Event.

The coding frame used is the OPCS 'Z' coding.The coding frame used is the OPCS-4 'Z' coding.

References:
National Cancer Dataset Version 1.3_ISB October 2002

 

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CLINICAL CLASSIFICATION CODE

Change to Attribute: Changed Description

A unique identifier for a CLINICAL CLASSIFICATION, for example this could be an OPCS-4 code or a Read code.A unique identifier for a CLINICAL CLASSIFICATION, for example this could be an OPCS-4 code or a Read code.

The codes for both OPCS-4 and Read are maintained by NHS Connecting for Health.The codes for both OPCS-4 and Read are maintained by NHS Connecting for Health.

This could also be a PATIENT DIAGNOSIS.

See International Classification of Diseases (ICD-10) and Read Coded Clinical Terms.

Diagnoses should be classified where possible using ICD-10 or other classification codes approved centrally for mapping to ICD-10 codes. Clinical Terms (The Read Codes) can be used in addition to ICD-10 codes for Patient Diagnosis. However Clinical Terms (The Read Codes) are not accepted for the purposes of central Hospital Episode Statistics data, where ICD-10 is mandatory.

ICD-10 diagnostic codes are at least four characters in length. The first character is always alphabetic. Where an undivided three character code is used, the fourth character must be filled with 'X'.

Fifth characters should be used in accordance with the guidance in Introduction.Fifth characters should be used in accordance with the guidance in International Classification of Diseases (ICD-10). Where they are not used the character must be filled with a '-'. The sixth character of the code is used to designate an asterisk or dagger indicator in ICD-10; it may be an 'A' or 'D'.

 

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PATIENT PROCEDURE IMPLANT INDICATION

Change to Attribute: Changed Description

An indication that a PATIENT requires an IMPLANT as a result of a Patient Procedure. Please note that other OPCS-4 codes can be used only where applicable. Please note that other OPCS-4 codes can be used only where applicable.

Examples are:

Hip Primary  
W37.1Primary total prosthetic replacement of hip joint using cement
W38.1Primary total prosthetic replacement of hip joint not using cement
W39.1Primary total prosthetic replacement hip joint not elsewhere classified (eg hybrid)
W39.1Primary total prosthetic replacement hip joint not elsewhere classified
W58.1Primary resurfacing arthroplasty of joint
  
Hip revision  
W37.3Revision of total prosthetic replacement of hip joint using cement
W38.3Revision of total prosthetic replacement of hip joint not using cement
W39.3Revision of total prosthetic replacement of hip joint not elsewhere classified (eg hybrid)
W39.3Revision of total prosthetic replacement of hip joint not elsewhere classified
W58.2Revision of resurfacing arthroplasty of joint
  
Knee primary  
W40.1Primary total prosthetic replacement of knee joint using cement
W41.1Primary total prosthetic replacement of knee joint not using cement
W42.1Primary total prosthetic replacement knee joint not elsewhere classified (eg hybrid)
W42.1Primary total prosthetic replacement knee joint not elsewhere classified
W52.1Primary prosthetic replacement of articulation of bone using cement nec
Z84.4Patellofemoral joint
Z84.6Knee joint
  
Knee revision  
W40.3Revision of total prosthetic replacement of knee joint using cement
W41.3Revision of total prosthetic replacement of knee joint not using cement
W42.3Revision of total prosthetic replacement of knee joint not elsewhere classified (eg hybrid)
W42.3Revision of total prosthetic replacement of knee joint not elsewhere classified

References:
National Joint Registry Dataset: v.1: 24th March 2003 

 

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ADMISSION INTENDED PROCEDURE

Change to Data Element: Changed Description

Format/length:n4
HES item: 
National Codes: 
Default Codes: 

Notes:
This is the code value list of OPCS codes used to:This is the code value list of OPCS-4 codes used to:

  • monitor specific targets (001 and 002), i.e. the "Patients waiting longer than three months (13 weeks) for revascularisation" target and
  • monitor waiting times (003 and 004) for other cardiovascular related procedures that are not specifically included in the target above.
  • monitor specific targets (0001 and 0002), i.e. the "Patients waiting longer than three months (13 weeks) for revascularisation" target and
  • monitor waiting times (0003 and 0004) for other cardiovascular related procedures that are not specifically included in the target above.

The groupings are based upon specified OPCS-4 codes as recorded by the CLINICAL CLASSIFICATION CODE of the CLINICAL CLASSIFICATION which is an OPERATIVE PROCEDURE for the PLANNED ACTIVITY of an ELECTIVE ADMISSION LIST ENTRY for a PATIENT being admitted electively.The groupings are based upon specified OPCS-4 codes as recorded by the CLINICAL CLASSIFICATION CODE of the CLINICAL CLASSIFICATION which is an OPERATIVE PROCEDURE for the PLANNED ACTIVITY of an ELECTIVE ADMISSION LIST ENTRY for a PATIENT being admitted electively.

When the OPCS-4 code of the OPERATIVE PROCEDURE is within the range of the specified ADMISSION INTENDED PROCEDURE for the sub group within the data set, the PATIENT should be included in the count providing all the other criteria of the count are also met.When the OPCS-4 code of the OPERATIVE PROCEDURE is within the range of the specified ADMISSION INTENDED PROCEDURE for the sub group within the data set, the PATIENT should be included in the count providing all the other criteria of the count are also met.

An Intended Patient Procedure is a PLANNED ACTIVITY where PLANNED ACTIVITY TYPE is National Code 04 'Intended Patient Procedure'.

One of the following values can be set:

OPCS-4 codes 
 OPCS-4 codes 
0001CABG - Coronary Artery Bypass Graft Code Range:
K40.- Saphenous vein graft replacement of coronary artery
K41.- Other autograft replacement of coronary artery
K42.- Allograft replacement of coronary artery
K43.- Prosthetic replacement of coronary artery
K44.- Other replacement of coronary artery
K45.- Connection of thoracic artery to coronary artery
K46.- Other bypass of coronary artery
0002PTCA - Percutaneous Transluminal Coronary Angioplasty Coding Range:
K49.- Transluminal balloon angioplasty of coronary artery
Excludes: Percutaneous transluminal balloon angioplasty and stenting of coronary artery (K75)
K50.1 Percutaneous transluminal laser coronary angioplasty
K75.- Percutaneous transluminal balloon angioplasty and stenting of coronary artery
Excludes: Transluminal balloon angioplasty of coronary artery (K49) 
0003Valves Coding Range
Open
K25.- Plastic repair of mitral valve
K26.- Plastic repair of aortic valve
K27.- Plastic repair of tricuspid valve
K28.- Plastic repair of pulmonary valve
K29.- Plastic repair of unspecified valve of heart
K30.- Revision of plastic repair of heart
K31.- Open incision of valve of heart
K34.- Other open operations on valve of heart
Closed
K32.- Closed incision of valve of heart
Therapeutic transluminal
K35.- Therapeutic transluminal operations on valve of heart
0002PTCA - Percutaneous Transluminal Coronary Angioplasty Coding Range:
K49.- Transluminal balloon angioplasty of coronary artery
Excludes: Percutaneous transluminal balloon angioplasty and insertion of stent into coronary artery (K75)
K50.1 Percutaneous transluminal laser coronary angioplasty
K75.- Percutaneous transluminal balloon angioplasty and insertion of stent into coronary artery
Excludes: Transluminal balloon angioplasty of coronary artery (K49) 
0003Valves Coding Range
Open
K25.- Plastic repair of mitral valve
K26.- Plastic repair of aortic valve
K27.- Plastic repair of tricuspid valve
K28.- Plastic repair of pulmonary valve
K29.- Plastic repair of unspecified valve of heart
K30.- Revision of plastic repair of valve of heart
K31.- Open incision of valve of heart
K34.- Other open operations on valve of heart
Closed
K32.- Closed incision of valve of heart
Therapeutic transluminal
K35.- Therapeutic transluminal operations on valve of heart
0004Angiography Coding Range
K63.- Contrast radiology of heart
K65.- Catheterisation of heart
 

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ADMITTED PATIENT NHS ADMISSIONS

Change to Data Element: Changed Description

Format/length:n10
HES item: 
National Codes: 
Default Codes: 

Notes:
This is the number of NHS PATIENTS admitted to a Hospital Provider Spell of an NHS provider within the REPORTING PERIOD for planned treatment activity for a particular ADMISSION INTENDED PROCEDURE.

That is where the ORGANISATION TYPE of the Health Care Provider ORGANISATION is classification c 'NHS Trust' or x 'Primary Care Trust' and the OPCS-4 code as recorded by the CLINICAL CLASSIFICATION CODE of the OPERATIVE PROCEDURE is within the group range of ADMISSION INTENDED PROCEDURE.That is where the ORGANISATION TYPE of the Health Care Provider ORGANISATION is classification c 'NHS Trust' or x 'Primary Care Trust' and the OPCS-4 code as recorded by the CLINICAL CLASSIFICATION CODE of the OPERATIVE PROCEDURE is within the group range of ADMISSION INTENDED PROCEDURE.

 

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ADMITTED PATIENT NON-NHS ADMISSIONS

Change to Data Element: Changed Description

Format/length:n10
HES item: 
National Codes: 
Default Codes: 

Notes:
This is the number of NHS PATIENTS admitted to a Hospital Provider Spell of a registered or unregistered non-NHS provider ORGANISATION within the REPORTING PERIOD for planned treatment activity for a particular ADMISSION INTENDED PROCEDURE.

That is where the ORGANISATION TYPE of the Health Care Provider ORGANISATION is classification q. 'Registered non-NHS Provider' or r. 'Unregistered non-NHS Provider (except Local Authority)' and the ADMINISTRATIVE CATEGORY CODE current at the START DATE of the Hospital Provider Spell is National Code 01 'NHS patient' and the OPCS-4 code as recorded by the CLINICAL CLASSIFICATION CODE of the OPERATIVE PROCEDURE is within the group range of ADMISSION INTENDED PROCEDURE. 'Unregistered non-NHS Provider (except Local Authority)' and the ADMINISTRATIVE CATEGORY CODE current at the START DATE of the Hospital Provider Spell is National Code 01 'NHS patient' and the OPCS-4 code as recorded by the CLINICAL CLASSIFICATION CODE of the OPERATIVE PROCEDURE is within the group range of ADMISSION INTENDED PROCEDURE.

 

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DIAGNOSTIC TEST (ENDOSCOPY)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended or actual endoscopy diagnostic test or procedure split by Colonoscopy, Flexi sigmoidoscopy, Cystoscopy and Gastroscopy for a SERVICE REQUEST derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics waiting times and activity: Guidance on completing the "diagnostic waiting times & activity" monthly data collection.This is the intended or actual endoscopy diagnostic test or procedure split by Colonoscopy, Flexi sigmoidoscopy, Cystoscopy and Gastroscopy for a SERVICE REQUEST derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics waiting times and activity: Guidance on completing the "diagnostic waiting times & activity" monthly data collection.

References:
Department of Health: Monthly and Quarterly/Biannual Diagnostics statistics

 

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DIAGNOSTIC TEST (ENDOSCOPY CENSUS)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended endoscopy DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census.This is the intended endoscopy DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census. 

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DIAGNOSTIC TEST (IMAGING)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended or actual Imaging Test or Procedure split by Magnetic Resonance Imaging (MRI), Computed Tomography (CT) scan, Non-obstetric ultrasound, Barium Enema and DEXA scan for a SERVICE REQUEST derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics waiting times and activity: Guidance on completing the "diagnostic waiting times & activity" monthly data collection.This is the intended or actual Imaging Test or Procedure split by Magnetic Resonance Imaging (MRI), Computed Tomography (CT) scan, Non-obstetric ultrasound, Barium Enema and DEXA scan for a SERVICE REQUEST derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics waiting times and activity: Guidance on completing the "diagnostic waiting times & activity" monthly data collection.

References:
Department of Health: Monthly and Quarterly/Biannual Diagnostics statistics

 

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DIAGNOSTIC TEST (IMAGING CENSUS)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended imaging DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census.This is the intended imaging DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census. 

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DIAGNOSTIC TEST (PATHOLOGY CENSUS)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended pathology DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census.This is the intended pathology DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census. 

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DIAGNOSTIC TEST (PHYSIOLOGICAL MEASUREMENT)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended or actual physiological measurement diagnostic test or procedure split by Audiology - audiological assessments, Cardiology - echocardiography and electrophysiology, Neurophysiology - peripheral neurophysiology, Respiratory physiology - sleep studies, Urodynamics - pressures and flows for a SERVICE REQUEST derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics waiting times and activity: Guidance on completing the "diagnostic waiting times & activity" monthly data collection.This is the intended or actual physiological measurement diagnostic test or procedure split by Audiology - audiological assessments, Cardiology - echocardiography and electrophysiology, Neurophysiology - peripheral neurophysiology, Respiratory physiology - sleep studies, Urodynamics - pressures and flows for a SERVICE REQUEST derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics waiting times and activity: Guidance on completing the "diagnostic waiting times & activity" monthly data collection.

References:
Department of Health: Monthly and Quarterly/Biannual Diagnostics statistics

 

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DIAGNOSTIC TEST (PHYSIOLOGICAL MEASUREMENT CENSUS)

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:

This is the intended physiological measurement DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS 4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census.This is the intended physiological measurement DIAGNOSTIC TEST or procedure (CLINICAL INTERVENTION) split by test grouping of SERVICE REQUESTS derived from the CLINICAL CLASSIFICATION OPCS-4 codes listed in the Department of Health document 'Diagnostics Census: Guidance on completing the "diagnostic waiting times" census. 

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HIGH COST DRUGS (OPCS)

Change to Data Element: Changed Description

Format/length:an4
National Codes:X81.0 - X97.9
Default Codes: 

Notes:
See PROCEDURE CODING for details on coding.

This is the use of high cost drugs as per OPCS definitions provided as a CARE ACTIVITY.This is the use of high cost drugs as per OPCS-4 definitions provided as a CARE ACTIVITY.

 

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HRG DOMINANT GROUPING VARIABLE-PROCEDURE

Change to Data Element: Changed Description

Format/length:annn
HES item: 
National Codes: 
Default Codes: 

Notes:
The National Schedule of Reference Costs, developed by the Department of Health, uses Healthcare Resource Groups as the basis for costing in-patient and day case services. Healthcare Resource Groups are derived from existing Commissioning Data Set data items using an algorithm and a software package developed by the Health and Social Care Information Centre .

The HRG DOMINANT GROUPING VARIABLE-PROCEDURES is a field derived by the Healthcare Resource Group Acute Inpatient Grouper. It represents the procedure that the Healthcare Resource Group grouping algorithm has identified as having the greatest effect upon the resources consumed by a PATIENT. It is required for the production of the National Schedule of Reference Costs reports.

The HRG DOMINANT GROUPING VARIABLE-PROCEDURES have the same data format, rules and attributes as OPCS-4 codes for Patient Procedure, see also PROCEDURE CODING.The HRG DOMINANT GROUPING VARIABLE-PROCEDURES have the same data format, rules and attributes as OPCS-4 codes for Patient Procedure, see also PROCEDURE CODING.

DSCN 08/2000 includes HRG DOMINANT GROUPING VARIABLE-PROCEDURES in the Commissioning Data Set to standardise the handling of this data item within the Commissioning Data Set and the Secondary Uses Service database. It is mandatory from 01/10/2001.

Patient Procedure is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 25 'Patient Procedure'.

 

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PRIMARY OPERATION (OPCS-4)

Change to Data Element: Changed Description

Format/length:an4
HES item:OPERATN1
National Codes: 
Default Codes: 

Notes:
See PROCEDURE CODING for details on coding.

'Primary' is a classification of PATIENT PROCEDURE CODING SIGNIFICANCE of INTERVENTION CLASSIFICATION ASSOCIATION for the OPCS code of an OPERATIVE PROCEDURE.'Primary' is a classification of PATIENT PROCEDURE CODING SIGNIFICANCE of INTERVENTION CLASSIFICATION ASSOCIATION for the OPCS-4 code of an OPERATIVE PROCEDURE.

 

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PRIMARY PROCEDURE (OPCS)

Change to Data Element: Changed Description

Format/length:an4
HES item: 
National Codes: 
Default Codes: 

Notes:
See PROCEDURE CODING for details on coding.

'Primary' is a classification of PATIENT PROCEDURE CODING SIGNIFICANCE of INTERVENTION CLASSIFICATION ASSOCIATION for the OPCS code of an OPERATIVE PROCEDURE.'Primary' is a classification of PATIENT PROCEDURE CODING SIGNIFICANCE of INTERVENTION CLASSIFICATION ASSOCIATION for the OPCS-4 code of an OPERATIVE PROCEDURE.

 

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PROCEDURE CODING

Change to Data Element: Changed Description

Format/length:annn for OPCS-4, an7 for Clinical Terms (The Read Codes)
HES item:OPERATN
National Codes: 
Default Codes:X998 - Out-patient procedure carried out but no appropriate OPCS-4 code available
 X999 - No out-patient procedure carried out

Notes:

This is a CLINICAL CLASSIFICATION CODE.

See OPCS Classification of Interventions and Procedures for Classification of Surgical Operations and Procedures (OPCS - 4) and Read Coded Clinical Terms.See OPCS Classification of Interventions and Procedures for Classification of Surgical Operations and Procedures (OPCS-4) and Read Coded Clinical Terms.

Record any operative procedures carried out, such as an endoscopy or electro-convulsive therapy (ECT), as part of the current consultant episode.

Clinical Terms (The Read Codes) (an7) may be used as an optional addition to OPCS-4.Clinical Terms (The Read Codes) (an7) may be used as an optional addition to OPCS-4.

The recording of procedures using OPCS-4 is now optional for the Out-Patient/Ward Attenders Commissiong Data Set. If required, a default procedure code may be used in the first procedure field and subsequent procedure fields space-filled.The recording of procedures using OPCS-4 is now optional for the Out-Patient/Ward Attenders Commissioning Data Set. If required, a default code may be used in the first procedure field and subsequent procedure fields space-filled.

The default codes are classified as entries in the Classification of Surgical Operations and Procedures Fourth Revision Consolidated Version (OPCS-4).Where providers locally use OPCS-4 codes with a fifth character added, this should be removed before inclusion in the Commissioning Data Set.

Where providers locally use OPCS-4 codes with a fifth character added, this should be removed before inclusion in the Commissioning Data Set.

 

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PROCEDURE CODING (DIABETES RELEVANT OPCS-4)

Change to Data Element: Changed Description

Format/length:annn for OPCS-4
Format/length:annn for OPCS-4 
HES item: 
National Codes: 
Default Codes: 

Notes:
Records the PROCEDURE CODING identified in the following relevant procedures associated with the diabetic condition.

OPCS-4 CodesOPCS-4 Codes

LASER (Ocular retinal photocoagulation) 
C82.1Cauterisation of lesion of retina
Y08.4Laser destruction (secondary procedure)
C82.1Cauterisation of lesion of retina
Includes: Photocoagulation of lesion of retina NEC; Electrocoagulation of lesion of retina NEC
Y08.4Laser destruction of lesion of organ NOC (secondary procedure)
MINOR AMPUTATION (amputation toe or below ankle) 
X11.1Amputation of great toe
X11.2Amputation of phalanax of toe
X11.2Amputation of phalanx of toe
X11.8Amputation of toe, other specified
X11.9Amputation of toe, unspecified
X10.1Amputation of foot through ankle
X10.8Amputation of foot, other specified
X10.9Amputation of foot, unspecified
MAJOR AMPUTATION (amputation leg, above or below knee) 
X09.3Amputation of leg above knee
X09.4Amputation of leg through knee
X09.5Amputation of leg below knee
RRT (End stage renal failure requiring renal replacement therapy) 
X40.1Compensation for renal failure, renal dialysis
X40.2Compensation for renal failure, peritineal dialysis
X40.3Compensation for renal failure, haemodialysis
X40.2Compensation for renal failure, peritoneal dialysis NEC
X40.3Compensation for renal failure, haemodialysis NEC
X40.8Compensation for renal failure, other specified
X40.9Compensation for renal failure, unspecified
M01.1Transplantation of kidney autotransplantation of kidney
M01.2Transplantation of kidney allotransplantation of kidney
M01.3Transplantation of kidney allotransplantation of kidney
M01.2Transplantation of kidney allotransplantation of kidney from live donor
M01.3Transplantation of kidney allotransplantation of kidney from cadaver NEC
M01.8Transplantation of kidney other specified
M01.9Transplantation of kidney unspecified
 

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PROCEDURE SCHEME IN USE

Change to Data Element: Changed Description

Format/length:an2
HES item: 
National Codes: 
Default Codes: 

Notes:
This is used in the Clinical Activity Group of the Commissioning Data Set to denote the scheme basis of an Intervention, Operation or A&E Treatment.This is used in the Clinical Activity Group of the Commissioning Data Set to denote the scheme basis of an Intervention, Operation or A&E Treatment.
CODE DESCRIPTION 
01Accident & Emergency Treatment
02OPCS-4
02OPCS-4 
03Read Version 1 (READ 4)
04Read Version 2 (READ 5)
05Read Version 3.0

Read Version 3.1 is not supported in the Commissioning Data Set.

CDS-XML Message:

The codes as specified above must be used in CDS-XML messages. 

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RESPONSIBLE CARE PROFESSIONAL CODE (OPCS)

Change to Data Element: Changed Description

Format/length:an8
HES item:See Hospital Episode Statistics Cross Reference Tables 
National Codes: 
Default Codes:C9999998 - Consultant, General Medical Council (GMC) number not known
 CD999998 - Dental Consultant: General Medical Council (GMC) number/ General Dental Council (GDC) number not known
 D9999998 - Dentist, Dental Practice Board (DPB) number not known
 G9999998 - General Medical Practitioner PPD Code not known
 H9999998 - Other care professional
 M9999998 - Midwife
 N9999998 - Nurse

Notes:
RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) is the GENERAL MEDICAL COUNCIL (GMC) NUMBER, Dental Practice Board or other professional registration code for the CARE PROFESSIONAL undertaking the OPCS-4 classified operative Patient Procedure.RESPONSIBLE CARE PROFESSIONAL CODE (OPCS) is the GENERAL MEDICAL COUNCIL (GMC) NUMBER, Dental Practice Board or other professional registration code for the CARE PROFESSIONAL undertaking the OPCS-4 classified operative Patient Procedure. This will usually, but not exclusively, be the lead care professional or a junior member of the same team.

Where the actual professional registration code is unknown or the professional is not a doctor or a dentist, the appropriate default code should be used.

Patient Procedure is a CLINICAL INTERVENTION where CLINICAL INTERVENTION TYPE is National Code 25 'Patient Procedure'.

 

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SARCOMA TUMOUR SITE

Change to Data Element: Changed Description

Format/length:an5
HES item: 
National Codes: 
Default Codes: 

Notes:
SARCOMA TUMOUR SITE is the same as the attribute CLINICAL CLASSIFICATION CODE

The body site classification of a sarcoma tumour, at a more detailed level than ICD-10 based on OPCS 'Z' coding for a sarcoma tumour.The body site classification of a sarcoma tumour, at a more detailed level than ICD-10 based on OPCS-4 'Z' coding for a sarcoma tumour.

National Codes:

Additional to OPCS codes

Z92.8Specified region of body not elsewhere classified (to be used for multiple body sites)
Z92.9Region of body not elsewhere classified(to be used for Unknown)
 

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For enquiries about this Data Set Change Notice, please email datastandards@nhs.net