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

HLTCC401B Mapping and Delivery Guide
Undertake complex clinical coding

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency HLTCC401B - Undertake complex clinical coding
Description This unit of competency describes the skills and knowledge required to undertake coding of moderately complex discharge summaries, medical reports and medical records, including the selection of the primary diagnosis and sequencing of other diagnoses for coding
Employability Skills This unit contains Employability Skills
Learning Outcomes and Application Work performed requires a range of well developed skills where discretion and judgement is required and individuals will take responsibility for their own outputs
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.
Prerequisites/co-requisites Pre-requisite unitThis unit must be assessed after successful achievement of pre-requisite:HLTCC301B Produce coded clinical data
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: Abstract clinical data from moderately complex medical records
  • Interpret and apply the Australian National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and medical records
  • Select appropriate conditions/diseases and procedures for coding from moderately complex medical records
  • Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records
  • Identify additional diagnoses and procedures
  • Establish the correct sequencing of diagnoses and procedures
       
Element: Assign codes relating to moderately complex medical records
  • Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties
  • Assign complete and accurate ICD-10-AM disease and ACHI procedure codes
  • Utilise resources where appropriate to assist in making coding decisions
  • Recognise problems relating to privacy and confidentiality of client information
  • Maintain confidentiality of medical records and client information at all times
  • Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes
  • Meet occupational health and safety duty of care requirements
       
Element: Maintain clinical coding records
  • Record, enter, edit and maintain a client information system of coded data (disease index)
  • Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation
  • Make amendments to data collection and coding activities in line with organisation requirements
  • Maintain and update own knowledge and skills to ensure that amendments are addressed as required
       


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.

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.

Critical aspects for assessment and evidence required to demonstrate this competency unit:

The individual being assessed must provide evidence of specified essential knowledge as well as skills

Consistency of performance should be demonstrated over the required range of situations relevant to the workplace

Access and equity considerations:

All workers in the health industry should be aware of access and equity issues in relation to their own area of work

All workers should develop their ability to work in a culturally diverse environment

In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people

Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities

Context of and specific resources for assessment:

Assessment must be completed in the workplace

Relevant guidelines, standards and procedures

Resources essential for assessment include:

ICD-10-AM, ACHI and ACS and relevant local coding requirements

a range of complex medical records

resources material

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.

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge:

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

Australian and relevant State/Territory clinical coding standards and protocols

Appropriate legislation

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

Professional ethics in clinical coding

Classifications and nomenclature used to achieve accurate clinical coding

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

Coding diseases and procedures with ICD-10-AM, ACHI and ACS coding manuals

Coding factors influencing health status

Coding relating to:

infectious and blood diseases

mental health

endocrine and musculoskeletal diseases

injuries and poisonings

neoplasms, digestive and skin diseases

respiratory and circulatory diseases

nervous system, eye, ear, nose and mouth diseases

genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions

Comprehensive knowledge of medical terminology and body systems

Current codes of practice and guidelines in relation to clinical coding

Sequencing of primary and additional diagnoses

Sequencing protocols for clinical coding

Sources of information relating to changes to clinical coding requirements

Timeframes for completing clinical coding

Essential skills:

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

Analyse moderately complex medical records from a range of specialties to produce coded clinical data

Apply Australian National Coding Standards to code moderately complex medical records

Complete coding of an average of four moderately complex medical records per hour

Enter data to at least 80%accuracy from moderately complex medical records

Identify necessary amendments to data collection and coding activities

Identify sequencing requirements in moderately complex medical records

Use appropriate resources to assist with moderately complex clinical coding requirements

Use ICD-10-AM, ACHI and ACS coding manuals

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

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.

Moderately complex medical records refer to:

Medical records resulting from an episode of care generally seen in health care facilities ranging from large to small size hospitals (AIHW National Hospital Peer Group Classifications A1-D1)

Medical information may be obtained from:

discharge summaries

medical reports

medical records

Resources may include:

MIMS

Medical abbreviations dictionary

Disease and procedure codes may include:

Coding for:

endocrine and musculoskeletal diseases

genitourinary, pregnancy, childbirth, the puerperium, the perinatal period and congenital conditions

infectious and blood diseases

injuries and poisonings

mental health

neoplasms, digestive and skin diseases

nervous system, eye, ear, nose and mouth diseases

respiratory and circulatory diseases

Client information systems may include:

Computerised systems

Manual systems

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
Interpret and apply the Australian National Coding Standards to identify clinical data from moderately complex discharge summaries, medical reports and medical records 
Select appropriate conditions/diseases and procedures for coding from moderately complex medical records 
Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records 
Identify additional diagnoses and procedures 
Establish the correct sequencing of diagnoses and procedures 
Apply Australian National Coding Standards where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties 
Assign complete and accurate ICD-10-AM disease and ACHI procedure codes 
Utilise resources where appropriate to assist in making coding decisions 
Recognise problems relating to privacy and confidentiality of client information 
Maintain confidentiality of medical records and client information at all times 
Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes 
Meet occupational health and safety duty of care requirements 
Record, enter, edit and maintain a client information system of coded data (disease index) 
Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation 
Make amendments to data collection and coding activities in line with organisation requirements 
Maintain and update own knowledge and skills to ensure that amendments are addressed as required 

Forms

Assessment Cover Sheet

HLTCC401B - Undertake 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

HLTCC401B - Undertake 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: