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Follow the links below to find material targeted to the unit's elements, performance criteria, required skills and knowledge

Elements and Performance Criteria

1. Elements define the essential outcomes
2. Abstract clinical data from highly complex medical records
   • Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties
   • Interpret and apply the Australian coding standards (ACS) to ensure correct assignment of codes from a varied and highly complex casemix
   • Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix
   • Identify additional diagnoses and procedures when coding a varied and highly complex casemix
3. Assign codes relating to highly complex medical records
   • Perform clinical coding on a broad casemix, utilising knowledge of medical science and applying International statistical classification of diseases and related health problems (ICD-10-AM), Australian classification of health interventions (ACHI) and ACS new edition changes
   • Apply ACS where appropriate, to ensure the correct assignment of codes when coding from highly complex medical records for a range of specialties
   • Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix
   • Utilise appropriateresources to make informed coding decisions relating to highly complex medical records
   • Ensure coding reflects the correct sequencing of diagnoses and procedures
   • Identify coding issues and determine appropriate solutions
   • Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes
   • Maintain confidentiality of medical records and client information at all times
   • Meet occupational health and safety duty of care requirements
4. Provide clinical coding expertise in the workplace
   • Add value to discussions regarding clinical coding within the coding unit
   • Provide mentoring support for entry level clinical coders
   • Supervise an entry level clinical coder and select appropriate medical records for them
   • Follow up with clinicians regarding ambiguities in documentation, where required
   • Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues
5. Maintain currency of data collection and coding
   • Record, enter, edit and maintain a client information system of coded data (disease index)
   • Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation
   • Identify necessary amendments to data collection and coding activities
   • Provide necessary information and training to ensure that amendments are implemented with maximum ease
   • Ensure computer software is updated to meet any adjustment needs
   • Monitor the implementation of amendments

Performance Evidence

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

used current coding manuals and standards to produce accurate and complete coded clinical data from a varied and highly complex casemix for at least 10 patients:

identified coding issues and conducted research using appropriate materials/resources and or clinical input to generate solutions

identified sequencing requirements

identified, interpreted and applied necessary amendments to data collection and coding activities

used appropriate resources to assist with highly complex clinical coding requirements

used manual or an interfaced computerised coding system to submit data or disease index

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Knowledge Evidence

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

the broad health industry context for clinical coding

coding factors influencing health status

definition of a clinical coder and clinical coding, and the purpose of coded data

current codes of practice and guidelines in relation to clinical coding, including professional ethics

Australian and relevant state/territory clinical coding standards and protocols

the way rules and conventions are applied to clinical data to achieve correct clinical codes

sequencing protocols for principal and additional diagnoses

timescales within which clinical coding must take place

classifications and nomenclature used to achieve accurate clinical coding

clinical data indexing, storage and mapping from clinical terms of classifications

comprehensive knowledge of medical terminology and body systems

sources of information relating to changes to clinical coding requirements

resources used to solve clinical coding problems

coding classifications relating to:

congenital malformations and deformations

endocrine, nutrition and metabolic diseases

injuries and external causes of injuries

neoplasms

infectious diseases

blood disorders

poisoning and external causes of poisoning

symptoms, signs and abnormal clinical findings

coding relating to:

circulatory system

dermatology and plastic surgery

drugs, alcohol and mental health

ear, nose, throat and dental

endocrine system

gastrointestinal and hepatobiliary systems

genitourinary system

haemotology

immunology and infectious diseases

neonatology and paediatrics

neurology and neurosurgery

oncology

ophthalmology

orthopaedics

poisoning, adverse reactions, post-procedural complications and sequelae of injuries, poisoning and other external causes

pregnancy and childbirth and the puerperium

respiratory system

trauma

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