SAQA 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.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Evaluate and assign ICD and Procedure Codes pertaining to Other Groups within the coding system 
SAQA US ID UNIT STANDARD TITLE
263994  Evaluate and assign ICD and Procedure Codes pertaining to Other Groups within the coding system 
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 evaluating and assigning International Statistical Classification of diseases and related health problems (ICD) and Procedure Codes pertaining to Other Groups within the coding system.

A person credited with this unit standard is able to:
  • Analyse clinical information and/or health records and assign ICD and Procedure Codes appropriately to patient records and coding databases.
  • Apply ICD and Procedure Code conventions and the South African ICD coding standards to the relevant documentation.
  • Identify and resolve problems when assigning ICD and Procedure Codes to patient records and coding databases to ensure integrity of data. 

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

    UNIT STANDARD RANGE 
    Other Groups include but are not limited to symptoms, signs, abnormal clinical and laboratory findings not elsewhere classified; external causes of morbidity and mortality; factors influencing health status and contact with health services; codes for special purposes. 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Analyse clinical information and/or health records and assign ICD and Procedure Codes appropriately to patient records and coding databases. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Clinical information and/or health records are evaluated for accuracy of ICD and Procedure Codes. 

    ASSESSMENT CRITERION 2 
    Clinical information and/or health records are analysed to extract the appropriate health information for assigning ICD and Procedure Codes to patient records and coding databases. 

    ASSESSMENT CRITERION 3 
    Clinical information is extracted in accordance with coding standards to ensure consistency and uniformity. 
    ASSESSMENT CRITERION RANGE 
    Coding standards include but are not limited to WHO and SA Coding Standards.
     

    ASSESSMENT CRITERION 4 
    Medical terminology and concepts are applied when coding in order to assign codes accurately. 

    ASSESSMENT CRITERION 5 
    Relevant clinical information is extracted and accurately coded to prevent over coding. 
    ASSESSMENT CRITERION RANGE 
    Relevant information includes but is not limited to that: Which is clinically relevant; affects the care of a patient; is a reason for giving treatment; will have implications for the use of healthcare resources.
     

    SPECIFIC OUTCOME 2 
    Apply ICD and procedure coding conventions and the South African ICD and Procedure Coding standards. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The ICD and procedural rules and conventions related to Other Groups within the coding system are interpreted to determine their impact on data. 

    ASSESSMENT CRITERION 2 
    The ICD and procedural rules and conventions related to Other Groups within the coding system are applied when assigning ICD and Procedure Codes to clinical information and/or health records to ensure validity of data. 

    ASSESSMENT CRITERION 3 
    The South African ICD and procedural coding standards and/or guidelines related to Other Groups within the coding system are applied when assigning ICD and procedural codes to clinical information and/or health records to ensure accuracy in coding. 

    SPECIFIC OUTCOME 3 
    Identify and resolve problems when assigning ICD and Procedure Codes to patient records and coding databases. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    ICD and Procedure Code data are evaluated to ensure the application of relevant coding rules and conventions for Other Groups. 

    ASSESSMENT CRITERION 2 
    ICD and Procedure Code data are evaluated to ensure the application of relevant coding standards and guidelines. 

    ASSESSMENT CRITERION 3 
    Problems identified in the recorded clinical information are analysed to determine the specific corrective action required. 

    ASSESSMENT CRITERION 4 
    Identified problems are resolved appropriately to ensure that accurate data are coded. 


    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 
    Identifying and solving problems in which responses display that responsible decisions using critical and creative thinking have been made when:
  • Evaluate and resolve problems identified when assigning ICD and Procedure Codes to patient records and coding databases. 

  • 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:
  • Accurately assigning ICD and Procedure Codes related to Other Groups within the coding system. 

  • UNIT STANDARD CCFO COLLECTING 
    Collecting, analysing, organising and critically evaluating information when:
  • Critiquing and evaluating clinical information and/or health records.
  • Critiquing and evaluating coded data. 

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