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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Utilise clinical coding terms, rules and conventions for diagnostic and Procedure Codes 
SAQA US ID UNIT STANDARD TITLE
263979  Utilise clinical coding terms, rules and conventions for diagnostic and Procedure Codes 
ORIGINATOR
Task Team - Diagnostic and Procedural Coding 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 09 - Health Sciences and Social Services Promotive Health and Developmental Services 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 5  Level TBA: Pre-2009 was L5 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
The skills, values and knowledge reflected in this unit standard are required by people in the field of diagnostic and procedural coding. Learners would be able to contribute to quality data in diagnostic and procedural coding by utilising terms, rules and conventions for ICD and procedural coding.

A person credited with this unit standard is able to:
  • Extrapolate the applicable clinical coding terms, rules and conventions for the interpretation of the relevant ICD and Procedure Codes.
  • Explain the rationale of the applicability of Clinical Coding terms, rules and conventions for the assignment of the relevant ICD and Procedure Codes.
  • Apply different applicable Clinical Coding terms, rules and conventions when assigning ICD and Procedure Codes. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    Communication at NQF Level 4. 

    UNIT STANDARD RANGE 
    N/A 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Extrapolate the applicable Clinical Coding terms, rules and conventions for the interpretation of the relevant ICD and Procedure Codes. 
    OUTCOME RANGE 
    Different classifications include but are not limited to ICD Volume 1, 2 & 3, South African Coding Standards Document, Volumes for Procedure coding. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The ICD Volumes are utilised to source clinical coding terms, rules and conventions when assigning ICD codes. 

    ASSESSMENT CRITERION 2 
    The Procedural Volumes are utilised to source clinical coding terms, rules and conventions when assigning Procedure Codes. 

    ASSESSMENT CRITERION 3 
    The purpose of the clinical coding terms, rules and conventions are analysed to reflect its uses when assigning ICD and Procedure Codes. 

    ASSESSMENT CRITERION 4 
    The value and uses of clinical coding terms, rules and conventions are explained in terms of the benefits for the medical, insurance and healthcare industries. 

    SPECIFIC OUTCOME 2 
    Explain the rationale of the applicability of Clinical Coding terms, rules and conventions for the ssignment of the relevant ICD and Procedure Codes. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The impact of applying clinical coding terms, rules and conventions is explained in terms of the correct assignment of the Diagnostic and Procedure Codes. 

    ASSESSMENT CRITERION 2 
    Clinical coding terms, rules and conventions, are explained in terms of their influence in the assignment of the appropriate Diagnostic and Procedure Codes. 

    ASSESSMENT CRITERION 3 
    The implications of non-compliance in the use of clinical coding terms, rules and conventions are described in terms of their impact on Diagnostic and Procedure Codes. 

    ASSESSMENT CRITERION 4 
    The specific clinical coding terms, rules and conventions are appropriately applied when assigning Diagnostic and Procedure Codes to ensure accuracy in coding. 

    SPECIFIC OUTCOME 3 
    Apply different applicable clinical coding terms, rules and conventions when assigning ICD and Procedure Codes. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Different terms, rules and conventions are used to ensure accuracy in coding when assigning a clinical code. 

    ASSESSMENT CRITERION 2 
    Different terms, rules and conventions are applied to reflect their uses for a specific purpose. 

    ASSESSMENT CRITERION 3 
    ICD and Procedure Codes are managed and assigned in accordance with clinical coding terms, rules and conventions to ensure consistency and uniformity in coding. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    The assessment will be governed by the policies and guidelines of the relevant Education and Training Quality Assuror (ETQA) that has jurisdiction over this field of learning.

    The assessor will (at the very least) be accredited and have a relevant qualification and be a subject matter expert in this learning area and at least have 3 years experience in the skills specific area, post qualification.

    The learner can be assessed against this unit standard to obtain credits or as part of an integrated assessment for a qualification.
  • Internal moderation.
  • External moderation.
  • An assessor, accredited by the relevant ETQA, will assess the learner's competency.
  • Assessment procedures will be supplied by the ETQA in alignment with NSB requirements.
  • All assessment activities must be fair, so that all candidates have equal opportunities. Activities must be free of gender, ethnic or other bias.
  • Assessment and moderation procedures, activities and tools must be transparent, affordable and support development within the field, sub-field and NQF.
  • Questions and answers to determine theoretical knowledge are expected.
  • Assessment of a portfolio of evidence.
  • Direct observation in simulated and/or controlled work conditions. 

  • UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
  • Role and responsibility of the World Health Organization (WHO).
  • Updates and revisions of coding.
  • Background to coding in South Africa.

    Role and responsibility of:
  • Specific users of morbidity data:
    > Healthcare Delivery Systems in South Africa.
    > Public and Private Hospitals.
    > Health Insurers.
  • Statistical classification.
  • Procedural classification. 

  • UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Identifying and solving problems in which responses display that responsible decisions using critical and creative thinking have been made when:
  • Updating of the classification and encourage discussions to improve the classification. 

  • UNIT STANDARD CCFO WORKING 
    Working effectively with others as a member of a team, group, organisation, and community during:
  • Applying reporting procedures.
  • Discussion and group work. 

  • UNIT STANDARD CCFO ORGANISING 
    Organising and managing oneself and one's activities responsibly and effectively when:
  • Assigning clinical codes. 

  • UNIT STANDARD CCFO COLLECTING 
    Collecting, analysing, organising and critically evaluating information when:
  • Critically evaluating health information for planning purposes. 

  • UNIT STANDARD CCFO COMMUNICATING 
    Communicating effectively using visual, mathematical and/or language skills in the modes of oral and/or written persuasion when:
  • Reporting.
  • Presentations of data. 

  • UNIT STANDARD CCFO SCIENCE 
    Using science and technology effectively and critically, showing responsibility towards the environment and health of others when:
  • Capturing data.
  • Reporting on data. 

  • UNIT STANDARD CCFO DEMONSTRATING 
    Demonstrating an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation when:
  • Understanding international and national coding systems.
  • Impact of updating classifications nationally and internationally.
  • The international and national recognition of data. 

  • UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    N/A 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  66389   Higher Certificate: Diagnostic and Procedural Coding  Level 5  NQF Level 05  Reregistered  2023-06-30  HW SETA 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    NONE 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.