Application of OPS
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.
Encoding using OPS - a practical example
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.
What needs to be observed?
The most important basic rules are:
- You can only encode what has been sufficiently and accurately documented.
- Encoding should always be as specific as possible. Remainder groups such as "Other" or "Not specified in detail" are only encoded in the actual absence of specific information.
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 decisions of the "Schlichtungsausschuss" (federal conciliation committee) pursuant to Section 19 KHG shall also be given priority. these decisions can also be found on the InEK website under "Schlichtungsausschuss nach § 19 KHG".
Please note: Since version 2021, the alphabetical directory to the OPS is no longer provided as ODT or PDF version, but only as TXT(CSV) version. The following application example is therefore of limited use, since the TXT version, unlike the ODT and PDF book versions, does not contain any permutations of text entries.
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.
How to encode a "Spalthauttransplantation am rechten Oberarm bei Verbrennung" (split skin graft on the upper right arm after burn injury)?
- Look in the Alphabetical Index, e.g. under "Spalthaut, - Transplantation, -- Oberarm" (split skin, - graft, -- upper arm) or under "Transplantation, - Spalthaut, -- Oberarm" (graft, - split skin, -- upper arm) or under "Oberarm, - Transplantation, -- Spalthaut" (upper arm, -graft, -- split skin). You cannot look under "Verbrennung " (burn injury), because that is a diagnosis, and diagnoses are only included in the OPS in exceptional circumstances.
- There you find the entry: "bei Verbrennung und Verätzung 5-925.07" (for burns and chemical burns) ", followed by a double arrow.
- When you then look up this code in the Tabular List, you find instead of the six-character code 5-925.07 the five-character entry " **5-925.0 Spalthaut (split skin)". To make sure that you are looking in the right context (nature of the procedure, topography), please turn to the superordinate entry 5-925. The class title reads: "Freie Hauttransplantation und Lappenplastik an Haut und Unterhaut bei Verbrennungen und Verätzungen, Empfängerstelle" (Free skin graft or flap plasty on dermis and hypodermis for burns and chemical burns, recipient site). This proves that you have arrived correctly at skin grafts for burn injuries. The entry is followed by one inclusion ("Inkl."), several exclusions ("Exkl.") and notes ("Hinw.").
- Start by checking the exclusions. Is the procedure that you intend to encode listed under exclusions? If that is the case, you need to select the code listed next to this procedure and look it up in the Tabular List. It is likely that the code to be used is the one found there. In our example, this is not the case.
- The next step is to read and heed the notes. In our example, the third note is of particular importance: "Die Lokalisation ist an der sechsten Stelle nach der Liste vor Kode 5-920 zu kodieren" (The sixth character is to be used to encode the localization in accordance with the list ahead of code 5-920). This corresponds with the double asterisk preceding the five-character code. The user instructions explain the use of the double asterisk as follows: "Codes marked with a double asterisk (**) to the left of the respective code indicate five-digit codes which require the use of a six-digit subclassification, generated by combining the 5-digit code with a list."
- Therefore turn back to code 5-920. Under the superordinate three-character entry "5-92 Operationen an Haut und Unterhaut bei Verbrennungen und Verätzungen" (Operations on dermis and hypodermis for burns and chemical burns), you find the note: "Die Lokalisation ist für die Kodes 5-920, 5-921 und 5-923 bis 5-929 nach folgender Liste zu kodieren:" (The topography for codes 5-920, 5-921 and 5-923 to 5-929 is to be encoded according to the following list:) This note thus also applies to the entry found in the Alphabetical Index: "**5-925.0 Spalthaut" (split skin). The subsequent list with codes from 0 to x contains possible localizations; for paired organs, the code is again marked with a double arrow (side reference required). The topographical information "Oberarm" (upper arm) is encoded as 7 double arrows. The five-character code 5-925.0 has to be supplemented in 6th place with the number 7 to make 5-925.07. This is exactly the code that you found in the Alphabetical Index.
- In the Alphabetical Index, the code and the added 7 were marked with a double arrow. The double arrow means that you need to add a side reference to the code (R for right, L for left, B for bilateral).
- Therefore, the required code for "Spalthauttransplantation am rechten Oberarm bei Verbrennung" (split skin graft on the upper right arm after burn injury) is 5-925.07 R.
- The identified code is only correct if you have correctly observed all exclusions and other notes in the superordinate group "Operationen an Haut und Unterhaut (5-89... 5-92)" (Operations on dermis and hypodermis) and in categories 5-92, 5-925 and 5-925.0."
- If you want to encode for the purposes of the G-DRG system, you must consider the DKR encoding guidelines.