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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Use coding resources to access information relevant to clinical coding 
SAQA US ID UNIT STANDARD TITLE
263981  Use coding resources to access information relevant to clinical coding 
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 services in diagnostic and Procedure Codes by using coding resources to access information relevant to clinical coding.

A person credited with this unit standard is able to:
  • Apply diagnostic and procedure rules and conventions to access relevant information in the Volumes for Procedure Codes when assigning ICD and Procedure Codes.
  • Interpret the use of the sections in the Volumes to access specific information.
  • Apply SA coding standards and guidelines to validate assigned codes.
  • Use coding resources to determine precision of assigned 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 
    Apply diagnostic and procedure rules and conventions to access relevant information in the Volumes for Procedure Coding when assigning ICD and Procedure Codes. 
    OUTCOME RANGE 
    Information is included in, but is not limited to: ICD Volumes 1, 2 & 3; Procedure Volumes. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Assigned ICD and Procedure Codes are evaluated to ensure that the coding rules and conventions are adhered to. 

    ASSESSMENT CRITERION 2 
    The use and application of rules and conventions in the Volumes are applied to access relevant health information. 

    ASSESSMENT CRITERION 3 
    The rules and conventions are applied to reflect relevant health information. 

    SPECIFIC OUTCOME 2 
    Interpret the use of the sections in the Volumes to access specific information. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Specific information is analysed to determine the accuracy in assigning ICD and Procedure Codes. 

    ASSESSMENT CRITERION 2 
    Rules and conventions are applied when accessing specific information in the Volumes to ensure consistency and accuracy in coding. 

    ASSESSMENT CRITERION 3 
    The result of inaccurate use of the rules and conventions are explained in terms of the impact on resources. 

    SPECIFIC OUTCOME 3 
    Apply SA coding standards and guidelines to validate assigned codes. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    SA coding standards and guidelines are scrutinised to ensure that the specific information is reflected when assigning ICD and Procedure Codes. 

    ASSESSMENT CRITERION 2 
    The World Health Organization and SA standards and guideline are analysed to ensure that the correct translation of clinical information into clinical codes is reflected. 

    ASSESSMENT CRITERION 3 
    WHO and SA Coding Standards are compared with one another to ensure that the national data matches the international data. 

    SPECIFIC OUTCOME 4 
    Use coding resources to determine precision of assigned codes. 
    OUTCOME RANGE 
    Coding resources include but are not limited to Volumes of ICD, Volumes of Procedures, Medical reports, South African Coding Standards Document, Medical terminology. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Allocated ICD and Procedure Codes are evaluated to reflect the impact on resources. 

    ASSESSMENT CRITERION 2 
    Various coding resources are used to provide quality data for comparison with own data. 

    ASSESSMENT CRITERION 3 
    Coding resources are analysed to reflect the benefits for the medical and health insurance environment. 

    ASSESSMENT CRITERION 4 
    The implications for assigning inaccurate codes are discussed in terms of the probable effects on the medical and health insurance environments. 


    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 
  • 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.
  • Electronic Communications and Transactions Act no 25 of 2002.
  • Access to Information Act no 2 of 2000.
  • Protection of Personal Information Bill.
  • Patient Rights Charter.
  • Privacy and Confidentiality document-Published by the National Task Team.
  • South African Standards Coding Standards.
  • Code of Ethics.
  • Purposes for coding.
  • Clinical education.
  • Reimbursement, e.g., case mix funding.
  • Specific uses of Morbidity data/Benefits:
    > Healthcare clinical decision-making and communication.
    > Leading causes of disease and injury.
    > Planning health programmes and services.
    > 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. 

  • 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:
  • Encourage discussions to improve the coding standards. 

  • 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 the appropriate ICD and Procedure Codes. 

  • UNIT STANDARD CCFO COLLECTING 
    Collecting, analysing, organising and critically evaluating information when:
  • Critically evaluating health information for statistical and re-imbursement 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
    Fundamental  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.