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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Analyse clinical information and assign ICD and Procedure Codes 
SAQA US ID UNIT STANDARD TITLE
263980  Analyse clinical information and assign ICD 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  10 
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 provide quality services in diagnostic and procedural coding by analysing clinical information and assigning ICD and Procedure Codes.

A person credited with this unit standard is able to:
  • Assign accurate ICD and Procedure Codes to health and data records.
  • Assess the impact of assigning inaccurate ICD and Procedure Codes.
  • Apply rules, conventions and medical terminology when assigning ICD and Procedure Codes. 

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

  • UNIT STANDARD RANGE 
    Clinical information includes and is not limited to health records, medical reports, and medical terminology. 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Assign accurate ICD and Procedure Codes to health and data records. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    ICD and Procedure Codes are assigned according to the healthcare services rendered, to ensure fair reimbursement. 

    ASSESSMENT CRITERION 2 
    Assigned codes are captured and/or recorded to inform statistics of diseases. 

    ASSESSMENT CRITERION 3 
    Assigned codes are evaluated for accuracy to ensure the quality of data. 

    SPECIFIC OUTCOME 2 
    Assess the impact of assigning inaccurate ICD and Procedure Codes. 
    OUTCOME RANGE 
    Inaccurate includes but is not limited to wrong, incomplete, incorrect, erroneous, invalid. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The impact of inaccurate coding is described in terms of reimbursement and possible litigation. 

    ASSESSMENT CRITERION 2 
    Inaccurate coding is described in terms of the impact on resources, health planning, budget, research, clinical risk management. 

    ASSESSMENT CRITERION 3 
    Documents and technology used for reference are analysed to determine the ease of use by the coder to prevent the assigning of inaccurate codes. 

    SPECIFIC OUTCOME 3 
    Apply rules, conventions and medical terminology when assigning ICD and Procedure Codes. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Assigned ICD and Procedure Codes are evaluated to ensure that coding rules and conventions have been consistently applied and guidelines are adhered to. 

    ASSESSMENT CRITERION 2 
    Coding rules and conventions are used to assign primary and secondary diagnoses to ensure an accurate set of data. 

    ASSESSMENT CRITERION 3 
    Sequencing rules are used to assign ICD and Procedure Codes to ensure consistency and uniformity in coding. 

    ASSESSMENT CRITERION 4 
    Medical terminology is used in context to ensure accurate translation of clinical information into codes. 


    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 SA.
  • Role and responsibility of:
    > National Department of Health (NDOH)
    > Council for Medical Schemes (CMS)
    > Private Higher Information Standards Committee (PHISC)
    > National Health Information System for South Africa (NHISSA)
    > National Task Team
    > Statistics South Africa (STATS SA)
    > Medical Research Council (MRC)
    > Board of Healthcare Funders (BHF)
    > Department of Home Affairs (DHA)
    > World Health Organisation (WHO)
    > South African Nursing Council (SANC)
    > South African Medical Association (SAMA)
    > Health Professions Council of South Africa (HPCSA)
    > Human Sciences Research Council (HSRC)
    > Hospital Association of South Africa (HASA)
    > National Health Laboratory Services (NHLS)
    > Correctional Services.
  • Purpose and uses of Diagnostic coding.
  • Privacy and Confidentiality.
  • South African Coding Standards.
  • Constitution of SA no 108 of 1996 Medical schemes Act no 131 of 1998.
  • Allied Health Professions Act no 63 of 1982
  • Children's Act no 38 of 2005
  • Termination of Pregnancy Act no 92 of 1996
  • Electronic Communications and Transactions Act no 25 of 2002
  • Health Act no 63 of 1977 Health professions Act no 56 of 1974
  • Mental Health Care Act no 17 of 2002
  • National Health Act no 61 of 2003
  • Nursing Act no 50 of 1978 and no 33 of 2005
  • Pharmacy Act no 53 of 1974
  • Access to Information Act no 2 of 2000
  • Protection of Personal Information Bill
  • Sterilization Act no 44 of 1998
  • Traditional Health Practitioners Act 35 of 2004
  • Patient Rights Charter
  • Privacy and Confidentiality document - Published by the National Task Team
  • South African Standards Coding Standards
  • Code of Ethics
  • Purposes for coding
  • Statistical outputs
  • Hospital disease indexing
  • Evidence for health policy
  • Planning and evaluating health services and programmes
  • Medical and public health research
  • Disease registries
  • Clinical education
  • Reimbursement, e.g., case mix funding
  • Specific uses of Morbidity data / Benefits
    > Quality and utilization of healthcare services
    > Quality assurance
    > Utilization of healthcare services
    > Healthcare clinical decision-making and communication
    > Monitor outcomes
    > Measure performance
    > Health situation and trend analysis
    > Leading causes of disease and injury
    > Notifiable diseases
    > Definition of policies and priorities
    > Planning health programmes and services
    > Public health.
    > Medical research.
    > Performance improvement activities.
    > Monitor service and resource utilization, analyze healthcare costs.
    > Health research and treatment development.
    > First or main source of information for certain diseases.
    > At local level, investigation of cases, disease control measures.
    > Specific population groups/problems (e.g., maternal and infant mortality, adolescents, elderly).
    > Healthcare management and policy decision-making.
  • Specific users of morbidity data.
    > Healthcare Delivery Systems in South Africa.
    > Public and Private Hospitals.
    > Health Insurers.
  • Open classification.
  • Closed classification.
  • Statistical classification.
  • Procedural classification.
  • Diagnostic classification.
  • Nomenclature.
  • Family of classification.
  • Updating process of the classification. 

  • UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Updating of the classification and encourage discussions to improve the classification. 

    UNIT STANDARD CCFO WORKING 
  • Applying reporting procedures.
  • Discussion and group work. 

  • UNIT STANDARD CCFO ORGANISING 
    Assigning clinical codes. 

    UNIT STANDARD CCFO COLLECTING 
    Critically evaluating health information for planning purposes. 

    UNIT STANDARD CCFO COMMUNICATING 
  • Reporting.
  • Presentations of data. 

  • UNIT STANDARD CCFO SCIENCE 
  • Capturing data.
  • Reporting on data. 

  • UNIT STANDARD CCFO DEMONSTRATING 
  • 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.