Unit of competency Outline
Date retreived
23/07/2026 10:33 PM AWST
23/07/2026 10:33 PM AWST
Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.
Complete highly complex clinical coding
Complete highly complex clinical coding
Unit of competency
National Code
HLTCC402B
HLTCC402B
State Code
D5818
D5818
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
02/08/2011
Field of Education
010103 - Statistics
Original Release Date
02/08/2011
Nominal Hours
20
Description
DescriptorThis unit of competency 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
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 National Coding Standards 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 Where appropriate, 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 ICD-10-AM, ACHI and ACS new edition changes
- 2.2 Apply Australian National Coding Standards 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 appropriate resources 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
RANGE STATEMENT
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Highly complex medical records refer to:
Medical records resulting from an episode of care in a principal referral hospital, a specialist women's and children's hospital and other specialist care facilities (AIHW National Hospital Peer Group Classifications A1-B2)
Medical information may be obtained from:
discharge summaries
medical reports
medical records
Appropriate resources may include:
Australian Coding Standards
Coding Matters
MIMS
Medical abbreviations dictionary
Other relevant material
Disease and procedure codes may include:
Coding for:
circulatory system
dermatology and plastic surgery
drugs, alcohol and mental health
ear, nose, throat and dental
endocrine system
gastrointestinal and hepatobiliary systems
genitourinary system
haemotology
immunology and infectious diseases
neonatology and paediatrics
neurology and neurosurgery
oncology
ophthalmology
orthopaedics
poisoning, adverse reactions, post-procedural complications and sequelae of injuries, poisoning and other external causes
pregnancy and childbirth
respiratory system
trauma
Client information systems may include:
Computerised systems
Manual systems
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Highly complex medical records refer to:
Medical records resulting from an episode of care in a principal referral hospital, a specialist women's and children's hospital and other specialist care facilities (AIHW National Hospital Peer Group Classifications A1-B2)
Medical information may be obtained from:
discharge summaries
medical reports
medical records
Appropriate resources may include:
Australian Coding Standards
Coding Matters
MIMS
Medical abbreviations dictionary
Other relevant material
Disease and procedure codes may include:
Coding for:
circulatory system
dermatology and plastic surgery
drugs, alcohol and mental health
ear, nose, throat and dental
endocrine system
gastrointestinal and hepatobiliary systems
genitourinary system
haemotology
immunology and infectious diseases
neonatology and paediatrics
neurology and neurosurgery
oncology
ophthalmology
orthopaedics
poisoning, adverse reactions, post-procedural complications and sequelae of injuries, poisoning and other external causes
pregnancy and childbirth
respiratory system
trauma
Client information systems may include:
Computerised systems
Manual systems
EVIDENCE GUIDE
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Consistency of performance should be demonstrated over the required range of situations relevant to the workplace
This unit must be assessed after successful achievement of the identified pre-requisite unit and extensive clinical coding work experience
Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
Resources essential for assessment include:
Relevant guidelines, standards and procedures
ICD-10-AM, ACHI and ACS and relevant local coding requirements
a range of medical records reflecting a varied and highly complex casemix from range of specialties
appropriate resource materials
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Consistency of performance should be demonstrated over the required range of situations relevant to the workplace
This unit must be assessed after successful achievement of the identified pre-requisite unit and extensive clinical coding work experience
Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
Resources essential for assessment include:
Relevant guidelines, standards and procedures
ICD-10-AM, ACHI and ACS and relevant local coding requirements
a range of medical records reflecting a varied and highly complex casemix from range of specialties
appropriate resource materials
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9126 | HLTCC402A | Complete highly complex clinical coding | Unit of competency |
Replaced By
| State Code | National Code | Title | Type |
|---|---|---|---|
| AVB12 | HLTADM007 | Complete highly complex clinical coding | Unit of competency |
| State Code | National Code | Title | Type |
|---|---|---|---|
| J094 | HLT43212 | Certificate IV in Health Administration | Qualification |