Unit of competency Outline

Date retreived
23/07/2026 1:01 AM AWST

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Complete highly complex clinical coding

Complete highly complex clinical coding

Unit of competency
National Code
HLTADM007
State Code
AVB12
TGA Status
Replaced
DTWD Status
Replaced
Current Release Number
1.00
Current Release Date
06/08/2015
View on TGA
State Implementation and Classification
Approved Date
22/01/2016
Field of Education
010103 - Statistics
Original Release Date
22/01/2016
Nominal Hours
20
Description
This unit describes the skills and knowledge required to complete coding of highly complex medical records with an advanced understanding of coding conventions, standards and practices in an extensive casemix.This unit applies to clinical coders who take responsibility for their own outputs, as well as mentoring other clinical coders as required.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.
Notes
Elements and Performance Criteria
1. Abstract clinical data from highly complex medical records
  • 1.1 Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties
  • 1.2 Interpret and apply the Australian coding standards (ACS) to ensure correct assignment of codes from a varied and highly complex casemix
  • 1.3 Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix
  • 1.4 Identify additional diagnoses and procedures when coding a varied and highly complex casemix
2. Assign codes relating to highly complex medical records
  • 2.1 Perform clinical coding on a broad casemix, utilising knowledge of medical science and applying International statistical classification of diseases and related health problems (ICD-10-AM), Australian classification of health interventions (ACHI) and ACS new edition changes
  • 2.2 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from highly complex medical records for a range of specialties
  • 2.3 Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix
  • 2.4 Utilise appropriateresources to make informed coding decisions relating to highly complex medical records
  • 2.5 Ensure coding reflects the correct sequencing of diagnoses and procedures
  • 2.6 Identify coding issues and determine appropriate solutions
  • 2.7 Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes
  • 2.8 Maintain confidentiality of medical records and client information at all times
  • 2.9 Meet occupational health and safety duty of care requirements
3. Provide clinical coding expertise in the workplace
  • 3.1 Add value to discussions regarding clinical coding within the coding unit
  • 3.2 Provide mentoring support for entry level clinical coders
  • 3.3 Supervise an entry level clinical coder and select appropriate medical records for them
  • 3.4 Follow up with clinicians regarding ambiguities in documentation, where required
  • 3.5 Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues
4. Maintain currency of data collection and coding
  • 4.1 Record, enter, edit and maintain a client information system of coded data (disease index)
  • 4.2 Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation
  • 4.3 Identify necessary amendments to data collection and coding activities
  • 4.4 Provide necessary information and training to ensure that amendments are implemented with maximum ease
  • 4.5 Ensure computer software is updated to meet any adjustment needs
  • 4.6 Monitor the implementation of amendments
No information
No information
Replaces
State Code National Code Title Type
D5818 HLTCC402B Complete highly complex clinical coding Unit of competency
Replaced By
State Code National Code Title Type
ODI47 HLTCCD008 Undertake highly complex clinical coding Unit of competency
State Code National Code Title Type
AD181 HLTSS00048 Clinical Coding Skill Set Skill set
AWM1 HLT47315 Certificate IV in Health Administration Qualification