HLTADM007 Complete highly complex clinical coding

Release: 1

HLTADM007 Complete highly complex clinical coding

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 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 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

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.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705