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Unit of competency details

HLTCCD010 - Analyse and report on clinical coding auditing (Release 2)

Summary

Usage recommendation:
Current
Release Status:
Current
Releases:
ReleaseRelease date
2 (this release) 02/Jul/2021
(View details for release 1) 30/Apr/2021

Companion volumes:
Unit of competency Assessment requirements

Delivery:
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Classifications

SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 080313 Public And Health Care Administration  

Classification history

SchemeCodeClassification valueStart dateEnd date
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 

Comments 

Release 2

Release 2 HLTCCD010 Analyse and report on clinical coding auditing supersedes and is equivalent to Release 1 HLTCCD010 Analyse and report on clinical coding auditing.

Updated:

Mapping details and minor corrections.

Release 1

HLTCCD010 Analyse and report on clinical coding auditing no equivalent unit.

Application

This unit describes the performance outcomes, skills and knowledge required to analyse and report on a clinical coding audit.

This unit applies to highly experienced clinical coders who have the expertise to audit clinically coded data. Work may be performed as an individual or as part of a team under limited supervision.

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 of competency. Refer to unit of competency for prerequisite requirements.

Unit code 

Unit title 

HLTCCD009 *

Undertake a clinical coding audit

Competency Field

Clinical Coding

Unit Sector

Health Administration

Elements and Performance Criteria

ELEMENTS 

PERFORMANCE CRITERIA 

Elements describe the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Compile clinical coding audit results.

1.1. List findings for each patient episode of care audited.

1.2. Analyse audit findings to determine audit outcomes.

1.3. Calculate and report error rates according to organisational requirements.

2. Prepare audit report.

2.1. Document purpose and methodology for audit.

2.2. Document audit findings including graphs and charts detailing error rates.

2.3. Identify and document common errors and areas for improvement.

2.4. List strategies and make recommendations for improving coding quality and direction of future audits.

2.5. Produce audit report and summarise findings maintaining confidentiality on individual coding results.

3. Provide feedback.

3.1. Provide feedback to the clinical coder on their audit results.

3.2. Participate in formal and informal meetings with management to discuss the audit report according to organisational procedures and protocols.

3.3. Manage audit dispute resolution process.

Foundation Skills

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

 

Assessment requirements

Modification History

Release 

Comments 

Release 2

Release 2 HLTCCD010 Analyse and report on clinical coding auditing supersedes and is equivalent to Release 1 HLTCCD010 Analyse and report on clinical coding auditing.

Updated:

Mapping details and minor corrections.

Release 1

HLTCCD010 Analyse and report on clinical coding auditing no equivalent unit.

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:

  • produce a report based on an audit of at least 50 records which includes:
  • key audit findings
  • percentage error rate
  • feedback for improvements
  • provide feedback to individual coders and management participating in the above audit.

Knowledge Evidence

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

  • current codes of practice and guidelines in relation to clinical coding, including professional ethics
  • relevant Australian State or Territory clinical coding standards and protocols
  • medical terminology and body systems
  • method of rules and conventions applied to clinical data for coding
  • sequencing protocols for clinical coding, including those for principal and additional diagnoses and interventions
  • key performance indicators (KPI’s) and quality indicators for coded clinical data
  • basic statistical data analysis methods
  • report writing techniques
  • techniques for delivering constructive feedback.

Assessment Conditions

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

Assessment must ensure access to:

  • a range of real-life patient health care records or de-identified real patient health care records either electronic or hard copy, that reflect current clinical practice
  • current Australian coding classifications
  • medical dictionary or other equivalent medical resource
  • organisational policies and procedures
  • National and State or Territory legislation relevant to clinical coding
  • personnel who would commonly participate in formal and informal meetings relating to internal and external audits

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

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