Assessment Requirements for HLTCCD007 Undertake moderately complex clinical coding

Release: 2

Assessment Requirements for HLTCCD007 Undertake moderately complex clinical coding

Modification History

Release	Comments
Release 2	Release 2 HLTCCD007 Undertake moderately complex clinical coding supersedes and is equivalent to Release 1 HLTCCD007 Undertake moderately complex clinical coding. Updated: Mapping details and minor corrections.
Release 1	HLTCCD007 Undertake moderately complex clinical coding supersedes and is not equivalent to HLTADM006 Undertake complex clinical coding.

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 moderately complex patient health care records for at least five 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, record, edit, amend and maintain validity of coded clinical data according to current classification standards and conventions

for the above, episodes of care should collectively include the following:

differing lengths of stay

both acute and chronic forms of a disease or condition

different care types

with disease or condition in different contexts including co-existing with multiple comorbidities and complications

participate in at least one coding audit of own work and:

identify type of coding audit and its purpose and prepare relevant patient health care records

respond to coding audit findings addressing any discrepancies.

meet organisational requirements for coding performance including not exceeding acceptable percentage error rate.

Knowledge Evidence

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

Australian and State or Territory clinical coding standards and protocols

rules and conventions applied to clinical data for coding

sequencing protocols for coding, including those for principal, and additional diagnoses and interventions

timescales within which coding must take place

key performance indicators (KPI’s) and quality indicators for coded clinical data

classifications and nomenclature for 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

purpose and types of coding audits

standard procedures and protocols for coding audits

common coding errors and how to calculate error rates

individual coder’s role in participating in coding audits and responding to audit findings.

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

moderately complex patient health care records from all clinical specialities to include single condition reason for admission with the existence of at least five multiple co-morbidities or the need for multiple interventions including:

multiple condition reason for admission without co-morbidities or the need for interventions:

minor multiple trauma

deliveries with complication

unplanned surgery

care type changes

preterm babies > 32 weeks

diabetes with multiple complications

neoplasms with metastases including single or multiple

single procedural complication or adverse effect of treatment

episodes where a clinical query might be required

current Australian coding classification

medical dictionary or other equivalent medical resource

organisational policies and procedures

National and State or 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