Application
This unit 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.
This unit applies to clinical coders.
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.
Elements and Performance Criteria
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 moderately complex medical records | 1.1 Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records 1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records 1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records 1.4 Identify additional diagnoses and procedures 1.5 Establish the correct sequencing of diagnoses and procedures |
2. Assign codes relating to moderately complex medical records | 2.1 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties 2.2 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes 2.3 Utilise 2.4 Recognise problems relating to privacy and confidentiality of client information 2.5 Maintain confidentiality of medical records and client information at all times 2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes 2.7 Meet work health and safety duty of care requirements |
3. Maintain clinical coding records | 3.1 Record, enter, edit and maintain a client information system of coded data (disease index) 3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation 3.3 Make amendments to data collection and coding activities in line with organisation requirements 3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required |
Evidence of Performance
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 moderately complex medical records across all specialities including:
discharge summaries
medical reports
medical records
produced accurate and complete coded clinical data for at least 20 different types patients, including those with:
differing length of stay
both acute and chronic forms of a disease or condition
different service category types
with disease or condition in different contexts (co-existing with multiple comorbidities and complications)
Evidence of Knowledge
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 clinical coding, including those for principle 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
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 classifications for diseases of:
circulatory system
digestive and hepatobiliary system
ear and mastoid process
eye and adnexa
nose and mouth
genitourinary system
musculoskeletal system
nervous system
respiratory system
skin and subcutaneous tissue
coding conditions:
relating to drugs, alcohol and mental health
in pregnancy, childbirth and the puerperium
originating in the perinatal period
Assessment Conditions
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:
real medical records either electronic or paper based
medical records from all clinical specialities
ICD-10-AM, Australian classification of health interventions (ACHI) and ACS coding manuals
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.
Foundation Skills
The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essential to performance. |
Foundation skills essential to performance are explicit in the performance criteria of this unit of competency. |