Unit of competency details
HLTCCD006 - Undertake basic clinical coding (Release 2)
Summary
Companion volumes:
Unit of competency
Assessment requirements
Training packages that include this unit
Qualifications that include this unit
Classifications
Classification history
ASCED Module/Unit of Competency Field of Education Identifier | 080313 | Public And Health Care Administration | 15/Jun/2021 | |
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Unit of competency
Modification History
Release
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Comments
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Release 2
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Release 2 HLTCCD006 Undertake basic clinical coding supersedes and is equivalent to Release 1 HLTCCD006 Undertake basic clinical coding.
Updated:
Mapping details and minor corrections.
|
Release 1
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HLTCCD006 Undertake basic clinical coding supersedes and is not equivalent to HLTADM005 Produce coded clinical data.
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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.
Unit code
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Unit title
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HLTCCD005*
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Abstract information for clinical coding
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Competency Field
Clinical Coding
Unit Sector
Health Administration
Elements and Performance Criteria
ELEMENTS
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PERFORMANCE CRITERIA
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Elements describe the essential outcomes
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Performance criteria describe the performance needed to demonstrate achievement of the element.
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1. Access basic patient health care records to evaluate clinical data.
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1.1. Access basic patient health care records according to organisational policies and procedures.
1.2. Ascertain episodes of care to be clinically coded.
1.3. Identify principal diagnosis and additional diagnoses for episodes of care.
1.4. Identify condition onset flag (COF).
1.5. Identify interventions for episodes of care.
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2. Assign codes to episodes of care.
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2.1. Assign diagnosis and intervention codes according to current classification indices, standards and conventions.
2.2. Determine sequencing of diagnoses codes according to current classification standards and conventions.
2.3. Assign condition onset flag (COF).
2.4. Determine sequencing of intervention codes according to current classification standards and conventions.
2.5. Establish sequencing of diagnoses and interventions according to the current coding standards for the episodes of care.
2.6. Use resources to assist in making coding decisions.
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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
Release
|
Comments
|
Release 2
|
Release 2 HLTCCD006 Undertake basic clinical coding supersedes and is equivalent to Release 1 HLTCCD006 Undertake basic clinical coding.
Updated:
Mapping details and minor corrections.
|
Release 1
|
HLTCCD006 Undertake basic clinical coding supersedes and is not equivalent to HLTADM005 Produce coded clinical data.
|
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