Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

HLTADM007 Mapping and Delivery Guide
Complete highly complex clinical coding

Version 1.0
Issue Date: April 2024


Qualification -
Unit of Competency HLTADM007 - Complete highly complex clinical coding
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to complete coding of highly complex medical records with an advanced understanding of coding conventions, standards and practices in an extensive casemix.This unit applies to clinical coders who take responsibility for their own outputs, as well as mentoring other clinical coders as required.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources, including:

medical records reflecting a varied and highly complex casemix from range of specialties

ICD-10-AM, ACHI and ACS coding manual

modelling of industry operating conditions, including:

presence of time constraints for coding activities

integration of situations requiring problem solving

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.
Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: Elements define the essential outcomes
       
Element: 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
       
Element: 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
       
Element: 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
       
Element: 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
       


Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Abstract clinical data from highly complex medical records

1.1 Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties

1.2 Interpret and apply the Australian coding standards (ACS) to ensure correct assignment of codes from a varied and highly complex casemix

1.3 Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix

1.4 Identify additional diagnoses and procedures when coding a varied and highly complex casemix

2. Assign codes relating to highly complex medical records

2.1 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

2.2 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from highly complex medical records for a range of specialties

2.3 Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix

2.4 Utilise appropriateresources to make informed coding decisions relating to highly complex medical records

2.5 Ensure coding reflects the correct sequencing of diagnoses and procedures

2.6 Identify coding issues and determine appropriate solutions

2.7 Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes

2.8 Maintain confidentiality of medical records and client information at all times

2.9 Meet occupational health and safety duty of care requirements

3. Provide clinical coding expertise in the workplace

3.1 Add value to discussions regarding clinical coding within the coding unit

3.2 Provide mentoring support for entry level clinical coders

3.3 Supervise an entry level clinical coder and select appropriate medical records for them

3.4 Follow up with clinicians regarding ambiguities in documentation, where required

3.5 Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues

4. Maintain currency of data collection and coding

4.1 Record, enter, edit and maintain a client information system of coded data (disease index)

4.2 Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation

4.3 Identify necessary amendments to data collection and coding activities

4.4 Provide necessary information and training to ensure that amendments are implemented with maximum ease

4.5 Ensure computer software is updated to meet any adjustment needs

4.6 Monitor the implementation of amendments

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

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

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Abstract clinical data from highly complex medical records

1.1 Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties

1.2 Interpret and apply the Australian coding standards (ACS) to ensure correct assignment of codes from a varied and highly complex casemix

1.3 Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix

1.4 Identify additional diagnoses and procedures when coding a varied and highly complex casemix

2. Assign codes relating to highly complex medical records

2.1 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

2.2 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from highly complex medical records for a range of specialties

2.3 Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix

2.4 Utilise appropriateresources to make informed coding decisions relating to highly complex medical records

2.5 Ensure coding reflects the correct sequencing of diagnoses and procedures

2.6 Identify coding issues and determine appropriate solutions

2.7 Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes

2.8 Maintain confidentiality of medical records and client information at all times

2.9 Meet occupational health and safety duty of care requirements

3. Provide clinical coding expertise in the workplace

3.1 Add value to discussions regarding clinical coding within the coding unit

3.2 Provide mentoring support for entry level clinical coders

3.3 Supervise an entry level clinical coder and select appropriate medical records for them

3.4 Follow up with clinicians regarding ambiguities in documentation, where required

3.5 Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues

4. Maintain currency of data collection and coding

4.1 Record, enter, edit and maintain a client information system of coded data (disease index)

4.2 Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation

4.3 Identify necessary amendments to data collection and coding activities

4.4 Provide necessary information and training to ensure that amendments are implemented with maximum ease

4.5 Ensure computer software is updated to meet any adjustment needs

4.6 Monitor the implementation of amendments

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
 
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 
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 
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 
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 

Forms

Assessment Cover Sheet

HLTADM007 - Complete highly complex clinical coding
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

Feedback to student

 

 

 

 

 

 

 

 

Assessor name:

Signature:

Date:

Assessment Record Sheet

HLTADM007 - Complete highly complex clinical coding

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: