Clinical Coding Draft 2

Project Summary

SkillsIQ, under the direction of the Technicians Support Services Industry Reference Committee (IRC), has undertaken a project to develop a new entry-level Clinical Coding qualification; one new skill set; seven new Clinical Coding Units of Competency; and the update of three existing Clinical Coding Units of Competency to ensure that entry-level clinical coders have access to appropriate skills and knowledge, in order to meet the current and future needs of the Australian health care system.
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The aim of the proposed development and update will ensure that the clinical coding workforce is equipped with the holistic skills and knowledge required to perform an entry-level clinical coder job role in a health setting in any jurisdiction. The proposed new qualification will create a consistent standard of practice for clinical coders.

The following key areas have been considered during the Training Package development and update process:

  • Clinical knowledge – medical science, medical terminology, anatomy and physiology
  • Health system knowledge – relevant to understanding the role of a clinical coder
  • Coding knowledge – use of the classifications, coding standards, conventions and guidelines
  • The ways in which coded data is used
  • Accessing and abstracting clinical information from medical records
  • Analysing and interpreting digital and paper medical records relevant to clinical coding
  • Knowledge of health funding models
  • Privacy and confidentiality, applying principles of privacy and ethics applicable to clinical coding
  • The role of a clinical coder, including participating in audits.
  • To inform the development of a new entry-level Clinical Coding qualification; one skill set; seven new Units of Competency and the update of three existing Clinical Coding Units of Competency, a Clinical Coding Technical Advisory Committee (TAC) was formed comprised of stakeholders and subject matter experts from across Australia. Formation of the TAC informed the identification and validation of the exact nature of the skills needs and knowledge requirements in the industry and the respective Training Package Product update requirements.

    As a result, the following developments have been proposed:

    • The development of a new entry level Clinical Coding qualification:
                       o Diploma of Clinical Coding
    • The Diploma of Clinical Coding comprises the following eight core Units of Competency:
                       o HLTCCD001 Understand the role of clinical coding within the health care system
                       o HLTCCD002 Interpret and navigate health records
                       o HLTCCD003 Use medical terminology in health care
                       o HLTCCD004 Establish knowledge of anatomy and physiology in a health care setting 
                       o HLTCCD005 Abstract information for clinical coding
                       o HLTCCD006 Undertake basic clinical coding
                       o HLTCCD007 Undertake moderately complex clinical coding
                       o HLTWHS001 Participate in workplace health and safety.
    • The following seven new Units of Competency have been developed to address the key skills and knowledge required by an entry-level clinical coder job role:
                       o HLTCCD001 Understand the role of clinical coding within the health care system
                       o HLTCCD002 Interpret and navigate health records
                       o HLTCCD003 Use medical terminology in health care
                       o HLTCCD004 Establish knowledge of anatomy and physiology in a health care setting
                       o HLTCCD005 Abstract information for clinical coding 
                       o HLTCCD009 Undertake a clinical coding audit
                       o HLTCCD010 Analyse and report for clinical coding auditing.
    • The following existing three Clinical Coding Units of Competency have been updated in terms of content and Unit codes:
                       o HLTADM005 Produce coded clinical data
                       (to be superseded by HLTCCD006 Undertake basic clinical coding)
                       o HLTADM006 Undertake complex clinical coding
                       (to be superseded by HLTCCD007 Undertake moderately complex clinical coding)
                       o HLTADM007 Complete highly complex clinical coding
                       (to be superseded by HLTCCD008 Undertake highly complex clinical coding)
    • A new skill set, Clinical Coding Auditor Skill Set, has been developed for experienced clinical coders seeking to broaden their skills to include clinical coding auditing.
    • The Skill Set comprises the following units:
                       o HLTCCD008 Undertake highly complex clinical coding
                       o HLTCCD009 Undertake a clinical coding audit
                       o HLTCCD010 Analyse and report for clinical coding auditing.
    • To take forward Training Package Product development work, the Clinical Coding TAC and the Technicians Support Services IRC have subsequently reviewed and confirmed the changes required for the development of Draft 2, based on feedback received from the first round of public consultation.

    Consultation Activities and Timelines

    National consultation on Draft 1 took place from 4th November 2019 to 13th December 2019. During this period input was sought on a proposed new draft qualification, one new skill set, eight new Units of Competency, three updated existing Units of Competency and their associated Assessment Requirements.

    Following the close of the consultation period, feedback received was collated and evaluated. This feedback has informed the development of Draft 2, which will shortly be publicly available for validation prior to the submission for endorsement.

    National validation on Draft 2 was open from Friday, 12th June and closed at 5:00pm on Monday, 6th July 2020.

    During this time SkillsIQ will be liaising with industry stakeholders, employers and subject matter experts. If you have expertise in these areas and would like to meet electronically with SkillsIQ, please contact Devika Mudaliar via devika.mudaliar@skillsiq.com.au or via phone at (02) 9392 8100.

    To remain up to date with project developments, please subscribe to SkillsIQ’s mailing list at https://www.skillsiq.com.au/Subscribetoournewsletter.aspx.

    Validation Activities:

    Webinars were held on the following dates:


    Date                                                                  Time

    Webinar 1: Wednesday, 17th June 2020     11.00am–12:00pm - closed
    Webinar 2: Wednesday, 24th June 2020     11.00am–12:00pm - closed
    Webinar 3: Wednesday, 1st July 2020         11.00am–12:00pm - closed

    Please click here to view the Clinical Coding Draft 2 webinar presentation.

    For further information, please contact Devika Mudaliar on (02) 9392 8100 or via email at devika.mudaliar@skillsiq.com.au.

Attachments

Clinical Coding Draft 2 Validation Guide

Recent Comments

kay bonello 06.07.2020

"I am just questioning the "Industry Standard" ,there is no detail on what is the Industry Standard for auditing, especially when it pertains to external coding audits. The rigour needed to assess an external coding auditor cannot be underestimated, the course completed by such an auditor is particularly important because of the financial and other performance-related implications directly impacted by the knowledge, capability, findings and recommendations of External Auditors. The existing Short course given by La Trobe University has such a delineation in their admission policy and assessment between an Internal Coding Auditor and an External Coding Auditor, this suggested course should not add confusion to potential employers who wish to employ an External Coding Auditor."

Clinical Coding Draft 2

HLTCCD009 Undertake a clinical coding audit Draft 2

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Helen Morgan 06.07.2020

"Should a pre-requisite of health administration course be required? Agree there is a need for student placements throughout the diploma so understanding of the health system is gained, especially if have not worked in health environment before. We need to ensure graduates are competent to communicate, understand a health organisations and their systems and how health care is delivered. Information Community Technology (ICT) ICT level of literacy is required for the diploma. "

Clinical Coding Draft 2

HLT50320 Diploma of Clinical Coding_Draft 2

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Helen Morgan 06.07.2020

"Coding quality edit reviews could be considered in this unit. For example, review data element and complies with a specific part of the data set. To build up to a bigger audit project. I am not sure if the theory of audit and practical auditing has been covered well. In terms of using standardised tool (such as ACBA) and looking at the quality improvement cycle. "

Clinical Coding Draft 2

HLTCCD009 Undertake a clinical coding audit Draft 2

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Helen Morgan 06.07.2020

"Is it the intent of this diploma to look at all types of coding and classification systems or just ICD for hospital inpatient data collection? Clinical coders need to learn about casemix and DRG classification system. Clinical Coders are working with the DRG system & evaluating the episode of care to ensure it has been grouped correctly to ensure it is clinically coherent and homogenous. To ensure no codes omitted or documentation that can be improved upon. Recommend to determine where information on health care terminologies and classifications can be incorporated into the Diploma. "

Clinical Coding Draft 2

HLTCCD005 Abstract information for clinical coding Draft 2

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Helen Morgan 06.07.2020

"Agree with comments about Coders need to know how to evaluate online resources. In NSW Health, we have CIAP which provides online access to evidence-based clinical information resources at the point of care. The purpose of CIAP is to facilitate evidence-based practice, improve access to clinical decision support, reduce adverse events, and improve clinician knowledge, with a view to enhancing the quality of patient care and improving patient outcomes. MIMs is available through CIAP, and is the source of truth we would use to look up drug information rather than a general internet search, where the information might not be reliable or evidence based. "

Clinical Coding Draft 2

HLTCCD004 Establish knowledge of anatomy and physiology in a health care setting Draft 2

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