Unit of competency Outline

Date retreived
23/07/2026 6:42 AM AWST

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Undertake moderately complex clinical coding

Undertake moderately complex clinical coding

Unit of competency
National Code
HLTCCD007
State Code
ODI48
TGA Status
Current
DTWD Status
Approved
Current Release Number
2.00
Current Release Date
02/07/2021
View on TGA
State Implementation and Classification
Approved Date
29/10/2021
Field of Education
080313 - Public And Health Care Administration
Original Release Date
29/10/2021
Nominal Hours
135
Description
This unit describes the performance outcomes, skills and knowledge required to assign clinical classification codes to an admitted episode of care using patient and clinical data from moderately complex patient health care records. This unit applies to clinical coders who are responsible for interpreting and extracting patient clinical information for the purposes of clinical coding. 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.
Notes
Elements and Performance Criteria
1. Abstract clinical data from moderately complex patient health care records.
  • 1.1. Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex patient health care records.
  • 1.2. Select conditions, diseases or procedures for coding from moderately complex patient health care records.
  • 1.3. Identify principal diagnosis for admissions when coding from moderately complex patient health care records.
  • 1.4. Identify additional diagnoses for admissions.
  • 1.5. Identify interventions for admissions.
2. Assign codes to episodes of care relating to moderately complex patient health care records.
  • 2.1. Assign diagnosis and intervention codes according to current classification indices, standards and conventions.
  • 2.2. Determine sequencing of diagnoses codes according to current classification standards and conventions.
  • 2.3. Assign condition onset flag (COF).
  • 2.4. Determine sequencing of intervention codes according to current classification standards and conventions.
  • 2.5. Use resources to assist in making coding decisions.
  • 2.6. Complete process of assigning codes from moderately complex patient health care records.
  • 2.7. Review and validate Diagnosis Related Group (DRG) assigned to episode of care.
3. Clarify coding queries.
  • 3.1. Identify additional and missing information and clarifications required for accurate coding.
  • 3.2. Formulate written coding queries and forward to clinical health care professionals according to Australian Coding Standards (ACS) and Clinical Coding Practice Framework (CCPF).
  • 3.3. Make verbal enquiries with clinical health care professionals according to national guidelines and organisational policies, procedures and protocols.
  • 3.4. Refer unresolved issues concerning clarity and accuracy of the clinical documentation and data according to organisational policies and procedures.
  • 3.5. Identify administrative data factors required for coding including ventilation hours and neonatal admission weight.
4. Maintain coding resources.
  • 4.1. Address changes to data collection and coding requirements according to relevant standards, protocols and legislation.
  • 4.2. Amend data collection and coding activities in line with organisational policies and procedures.
  • 4.3. Identify and address own knowledge and skills gaps to ensure deficits are addressed.
5. Participate in coding audits.
  • 5.1. Identify and prepare patient health care records for coding audit according to organisational policies and procedures.
  • 5.2. Independently validate own coding and interpret and resolve coding error findings across moderately complex patient health care records.
  • 5.3. Participate in processes to review coding audit findings.
No information
No information
Replaces
State Code National Code Title Type
AVB13 HLTADM006 Undertake complex clinical coding Unit of competency
State Code National Code Title Type
BGW4 HLT50321 Diploma of Clinical Coding Qualification