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.
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 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 appropriate 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 |
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 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
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 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
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:
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.
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. |