HLTADM006 Undertake complex clinical coding

Release: 1

HLTADM006 Undertake 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 undertake coding of moderately complex discharge summaries, medical reports and medical records, including the selection of the primary diagnosis and sequencing of other diagnoses for coding.

This unit applies to clinical coders.

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 moderately complex medical records	1.1 Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records 1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records 1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records 1.4 Identify additional diagnoses and procedures 1.5 Establish the correct sequencing of diagnoses and procedures
2. Assign codes relating to moderately complex medical records	2.1 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties 2.2 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes 2.3 Utilise resources where appropriate to assist in making coding decisions 2.4 Recognise problems relating to privacy and confidentiality of client information 2.5 Maintain confidentiality of medical records and client information at all times 2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes 2.7 Meet work health and safety duty of care requirements
3. Maintain clinical coding records	3.1 Record, enter, edit and maintain a client information system of coded data (disease index) 3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation 3.3 Make amendments to data collection and coding activities in line with organisation requirements 3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required

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