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Evidence Guide: HLTADM007 - Complete highly complex clinical coding

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

HLTADM007 - Complete highly complex clinical coding

What evidence can you provide to prove your understanding of each of the following citeria?

Elements define the essential outcomes

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Abstract clinical data from highly complex medical records

  1. Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties
  2. Interpret and apply the Australian coding standards (ACS) to ensure correct assignment of codes from a varied and highly complex casemix
  3. Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix
  4. Identify additional diagnoses and procedures when coding a varied and highly complex casemix
Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assign codes relating to highly complex medical records

  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. Apply ACS where appropriate, to ensure the correct assignment of codes when coding from highly complex medical records for a range of specialties
  3. Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix
  4. Utilise appropriateresources to make informed coding decisions relating to highly complex medical records
  5. Ensure coding reflects the correct sequencing of diagnoses and procedures
  6. Identify coding issues and determine appropriate solutions
  7. Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes
  8. Maintain confidentiality of medical records and client information at all times
  9. Meet occupational health and safety duty of care requirements
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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure coding reflects the correct sequencing of diagnoses and procedures

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify coding issues and determine appropriate solutions

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain confidentiality of medical records and client information at all times

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Meet occupational health and safety duty of care requirements

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Provide clinical coding expertise in the workplace

  1. Add value to discussions regarding clinical coding within the coding unit
  2. Provide mentoring support for entry level clinical coders
  3. Supervise an entry level clinical coder and select appropriate medical records for them
  4. Follow up with clinicians regarding ambiguities in documentation, where required
  5. Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues
Add value to discussions regarding clinical coding within the coding unit

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Provide mentoring support for entry level clinical coders

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Follow up with clinicians regarding ambiguities in documentation, where required

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain currency of data collection and coding

  1. Record, enter, edit and maintain a client information system of coded data (disease index)
  2. Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation
  3. Identify necessary amendments to data collection and coding activities
  4. Provide necessary information and training to ensure that amendments are implemented with maximum ease
  5. Ensure computer software is updated to meet any adjustment needs
  6. Monitor the implementation of amendments
Record, enter, edit and maintain a client information system of coded data (disease index)

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify necessary amendments to data collection and coding activities

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure computer software is updated to meet any adjustment needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Monitor the implementation of amendments

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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

Required Skills and Knowledge

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