Unit of competency details

Descriptor 

This unit of competency 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

Application 

Work performed requires independent application of a range of well developed skills where a high level of discretion and judgement is required

Individuals will take responsibility for their own outputs, as well as mentoring other clinical coders as required

Pre-requisite unit 

This unit must be assessed after successful achievement of pre-requisite and extensive clinical coding work experience:

• HLTCC401B Undertake complex clinical coding

Employability Skills 

This unit contains Employability Skills

Elements define the essential outcomes of a unit of competency.

The Performance Criteria specify the level of performance required to demonstrate achievement of the Element. Terms in italics are elaborated in the Range Statement.

ELEMENT 

PERFORMANCE CRITERIA 

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 National Coding Standards 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 Where appropriate, 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 ICD-10-AM, ACHI and ACS new edition changes

2.2 Apply Australian National Coding Standards 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 resources  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 

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:

• Advanced knowledge of Australian and relevant State/Territory clinical coding conventions, standards and practices
• Appropriate legislation
• Application of 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 factors influencing health status
• 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
• respiratory system
• trauma

• Comprehensive knowledge of medical terminology and body systems
• Current codes of practice and guidelines in relation to clinical coding
• Sequencing of codes and primary diagnosis
• Sequencing protocols for clinical coding
• Sources of information relating to changes to clinical coding requirements
• Timescales within which clinical coding must take place

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 a varied and highly complex casemix from a range of specialties to produce coded clinical data
• Apply Australian National Coding Standards to code highly complex medical records in an extensive casemix
• Complete coding of an average of four highly complex medical records per hour
• Enter data to at least 80%accuracy from highly complex medical records
• Identify coding issues and conduct research using appropriate materials/resources and or clinical input to generate solutions
• Identify sequencing requirements in varied and complex medical records
• Identify, interpret and apply necessary amendments to data collection and coding activities
• Research and secure information to manage coding questions and complications
• Use appropriate resources to assist with highly complex clinical coding requirements
• Use manual or an interfaced computerised coding system to submit data or disease index

EVIDENCE GUIDE 

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
• This unit must be assessed after successful achievement of the identified pre-requisite unit and extensive clinical coding work experience

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 :

• Resources essential for assessment include:

• Relevant guidelines, standards and procedures
• ICD-10-AM, ACHI and ACS and relevant local coding requirements
• a range of medical records reflecting a varied and highly complex casemix from range of specialties
• appropriate resource materials

RANGE STATEMENT 

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.

Highly complex medical records refer to :

• Medical records resulting from an episode of care in a principal referral hospital, a specialist women's and children's hospital and other specialist care facilities (AIHW National Hospital Peer Group Classifications A1-B2)
• Medical information may be obtained from:

• discharge summaries
• medical reports
• medical records

Appropriate resources may include :

• Australian Coding Standards
• Coding Matters
• MIMS
• Medical abbreviations dictionary
• Other relevant material

Disease and procedure codes may include :

• Coding for:

• 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
• respiratory system
• trauma

Client information systems may include :

• Computerised systems
• Manual systems