Unit of competency details

HLTADM006 - Undertake complex clinical coding (Release 1)

Summary

Releases:
ReleaseStatusRelease date
1 1 (this release)Current 06/Aug/2015

Usage recommendation:
Current
Mapping:
MappingNotesDate
Supersedes HLTCC401B - Undertake complex clinical codingThis version was released in HLT Health Training Package release 2.0 and meets the requirements of the 2012 Standards for Training Packages. Minimal changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency. Removed prerequisite. 05/Aug/2015


Training packages that include this unit

Classifications

SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 010103 Statistics  

Classification history

SchemeCodeClassification valueStart dateEnd date
ASCED Module/Unit of Competency Field of Education Identifier 010103 Statistics  02/Nov/2015 
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Unit Of competency

Modification History

Release 

Comments 

Release 1

This version was released in HLT Health Training Package release 2.0 and meets the requirements of the 2012 Standards for Training Packages.

Minimal changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency. Removed prerequisite.

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 Utiliseresources where appropriate to assist in making coding decisions

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

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.

Unit Mapping Information

No equivalent unit.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.education.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705

 

Assessment requirements

Modification History

Release 

Comments 

Release 1

This version was released in HLT Health Training Package release 2.0 and meets the requirements of the 2012 Standards for Training Packages.

Minimal changes to the elements and performance criteria. New evidence requirements for assessment, including volume and frequency. Removed prerequisite.

Performance Evidence

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)

Knowledge Evidence

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.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.education.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705

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