Unit of competency

Modification History

Application

This unit describes the performance outcomes, skills and knowledge required to assign clinical classification codes to an admitted episode of care using patient and clinical data from basic patient health care records.

This unit applies to clinical coders who are responsible for understanding and extracting patient clinical information for the purposes of clinical coding.

The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian standards and industry codes of practice.

No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.

Pre-requisite Unit

Note: Units marked with an asterisk* include one or more prerequisite units. Refer to unit of competency for prerequisite requirements.

Competency Field

Clinical Coding

Unit Sector

Health Administration

Elements and Performance Criteria

Foundation Skills

Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.

Unit Mapping Information

HLTCCD006 Undertake basic clinical coding supersedes and is not equivalent to HLTADM005 Produce coded clinical data.

Links

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

Assessment requirements

Modification History

Performance Evidence

Evidence of the ability to complete tasks outlined in elements and performance criteria of this unit in the context of the job role, and:

• use current coding manuals and standards to produce coded clinical data from basic patient health care records for at least ten episodes of care for each of the following:

• infectious and parasitic diseases
• neoplasms
• diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
• endocrine, nutritional and metabolic diseases
• mental and behavioural disorders
• diseases of the nervous system
• diseases of the eye and adnexa
• diseases of the ear and mastoid process
• diseases of the circulatory system
• diseases of the respiratory system
• diseases of the digestive system
• diseases of the skin and subcutaneous tissue
• diseases of the musculoskeletal system and connective tissue
• diseases of the genitourinary system
• pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
• symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
• injury, poisoning and causes of morbidity and mortality

• for each of the above, use reference materials to inform code assignment for unfamiliar clinical concepts
• for the above, episodes of care should collectively include the following:

• same-day episodes of care cases
• minor injuries
• basic surgeries
• overnight episodes of care
• both acute and chronic forms of a disease or condition.

Knowledge Evidence

Demonstrated knowledge required to complete the tasks outlined in elements and performance criteria of this unit:

• definition of a clinical coder and clinical coding, and the purpose of coded clinical data
• codes of practice and guidelines in relation to clinical coding, including professional ethics
• Australian and State/Territory clinical coding standards and protocols
• rules and conventions applied to clinical data and relevant to coding
• sequencing protocols for clinical coding, including those for principal, additional diagnoses and interventions
• timescales within which clinical coding must take place
• key performance indicators (KPI’s) and quality indicators for coded clinical data
• classifications and nomenclature relevant to clinical coding
• coding classifications, standards and conventions for:

• infectious and parasitic diseases
• neoplasms
• diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
• endocrine, nutritional and metabolic diseases
• mental and behavioural disorders
• diseases of the nervous system
• diseases of the eye and adnexa
• diseases of the ear and mastoid process
• diseases of the circulatory system
• diseases of the respiratory system
• diseases of the digestive system
• diseases of the skin and subcutaneous tissue
• diseases of the musculoskeletal system and connective tissue
• diseases of the genitourinary system
• pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
• symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
• injury, poisoning and causes of morbidity and mortality.

Assessment Conditions

Skills must be demonstrated in the workplace or in a simulated environment that reflects workplace conditions.

Assessment must ensure access to:

• real-life patient health care records or de-identified real patient health care records either electronic or hard copy, that reflect current clinical practice
• basic patient health care records to include single condition reason for admission with up to two co-morbidities or an intervention including:

• planned day surgery or treatment
• uncomplicated deliveries
• term babies with minor complications
• single trauma
• acute on chronic conditions

• current Australian coding classification
• medical dictionary or other equivalent medical resource
• organisational policies and procedures
• National and State/Territory legislation relevant to clinical coding

Assessors must satisfy the Standards for Registered Training Organisations’ requirements for assessors.

Links

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