In the following, you find instructions on the application rules that apply and the use of OPS. In addition, we provide some examples on the purposes of encoding according to OPS.
OPS is a procedural classification, i.e. a system of ordering to make content accessible, e.g. the contents of a health record or a case documentation: What is the group of operations, procedures and medical measures in the classification that the measures/procedures described in clear text in the documentation have to be assigned to? Which codes represent them accurately? Encoding is the assignment of the relevant code or codes.
The most important basic rules are:
The brochure on basic knowledge encoding provides a brief introduction to the use of OPS and ICD-10-GM.
The preface to the Tabular list contains a Guide to Encoding.
The individual categories of the Tabular List often contain code-specific information, e.g. in the form of definitions of diagnoses, inclusions and exclusions, coding hints and subclassifications. Similar information may also be provided for the higher hierarchy levels, i.e. under subgroup, blockand chapter headings; this information needs to be heeded for subordinate codes.
The FAQs deal with general questions on ICD and encoding as well as some code-specific questions on ICD-10-GM (only available in German language).
Priority is to be given to coding guidelines issued by the self-governing partners for some specific areas of application: "Deutsche Kodierrichtlinien DKR" (German Coding Guidelines) for inpatient care and "Deutsche Kodierrichtlinien Psychiatrie/Psychosomatik DKR-Psych" (German Coding Guidelines for Psychiatry/Psychosomatics). You find the "Kodierrichtlinien" on the InEK website on the folder G-DRG-System and PEPP-Entgeltsystem of the respective year.
The easiest option is to encode using the Alphabetical Index. It contains more than 70,000 entries on operations, procedures and medical measures in alphabetical order, each associated with the appropriate OPS code. Procedures can be found under the name of the procedure and - if the procedure is linked to a particular anatomical site - also under its topography.
However, it is essential that you cross-check the code from the Alphabetical index in the Tabular List. First, this is to ensure that the code you have found is in the right context within the Tabular List. Second, the various hierarchical levels of the classification may well contain specific coding notes in respect of the specific code, the group of codes or the entire chapter.