NTISthis.com

Evidence Guide: HLTCC402B - Complete highly complex clinical coding

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

HLTCC402B - Complete highly complex clinical coding

What evidence can you provide to prove your understanding of each of the following citeria?

Abstract clinical data from highly complex medical records

  1. Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties
  2. Interpret and apply the Australian National Coding Standards to ensure correct assignment of codes from a varied and highly complex casemix
  3. Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix
  4. Where appropriate, identify additional diagnoses and procedures when coding a varied and highly complex casemix
Abstract appropriate conditions/diseases and procedures from highly complex medical records from a range of specialties

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Interpret and apply the Australian National Coding Standards to ensure correct assignment of codes from a varied and highly complex casemix

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify the principal diagnosis and principal procedure for an admission when coding a varied and highly complex casemix

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Where appropriate, identify additional diagnoses and procedures when coding a varied and highly complex casemix

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assign codes relating to highly complex medical records

  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. 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
  3. Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix
  4. Utilise appropriate resources to make informed coding decisions relating to highly complex medical records
  5. Ensure coding reflects the correct sequencing of diagnoses and procedures
  6. Identify coding issues and determine appropriate solutions
  7. Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes
  8. Maintain confidentiality of medical records and client information at all times
  9. Meet occupational health and safety duty of care requirements
Perform clinical coding on a broad casemix, utilising knowledge of medical science and applying ICD-10-AM, ACHI and ACS new edition changes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assign complete and accurate ICD-10-AM disease and ACHI procedure codes abstracted from a varied and highly complex casemix

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Utilise appropriate resources to make informed coding decisions relating to highly complex medical records

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure coding reflects the correct sequencing of diagnoses and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify coding issues and determine appropriate solutions

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete the process of assigning the correct codes from highly complex medical records within appropriate timeframes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain confidentiality of medical records and client information at all times

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Meet occupational health and safety duty of care requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide clinical coding expertise in the workplace

  1. Add value to discussions regarding clinical coding within the coding unit
  2. Provide mentoring support for entry level clinical coders
  3. Supervise an entry level clinical coder and select appropriate medical records for them
  4. Follow up with clinicians regarding ambiguities in documentation, where required
  5. Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues
Add value to discussions regarding clinical coding within the coding unit

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide mentoring support for entry level clinical coders

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Supervise an entry level clinical coder and select appropriate medical records for them

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Follow up with clinicians regarding ambiguities in documentation, where required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct research using appropriate materials/ resources and or clinical input to generate solutions to address clinical coding issues

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain currency of data collection and coding

  1. Record, enter, edit and maintain a client information system of coded data (disease index)
  2. Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation
  3. Identify necessary amendments to data collection and coding activities
  4. Provide necessary information and training to ensure that amendments are implemented with maximum ease
  5. Ensure computer software is updated to meet any adjustment needs
  6. Monitor the implementation of amendments
Record, enter, edit and maintain a client information system of coded data (disease index)

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Secure and interpret changes to data collection and coding requirements, according to relevant standards, protocols and legislation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify necessary amendments to data collection and coding activities

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide necessary information and training to ensure that amendments are implemented with maximum ease

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure computer software is updated to meet any adjustment needs

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor the implementation of amendments

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

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

Required Skills and Knowledge

This describes the essential skills and knowledge and their level required for this unit.

Essential knowledge:

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes knowledge of:

Advanced knowledge of Australian and relevant State/Territory clinical coding conventions, standards and practices

Appropriate legislation

Application of professional ethics in clinical coding

Classifications and nomenclature used to achieve accurate clinical coding

Clinical data indexing, storage and mapping from clinical terms of classifications

Coding factors influencing health status

Coding relating to:

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

Comprehensive knowledge of medical terminology and body systems

Current codes of practice and guidelines in relation to clinical coding

Sequencing of codes and primary diagnosis

Sequencing protocols for clinical coding

Sources of information relating to changes to clinical coding requirements

Timescales within which clinical coding must take place

Essential skills:

It is critical that the candidate demonstrate the ability to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role

This includes the ability to:

Analyse a varied and highly complex casemix from a range of specialties to produce coded clinical data

Apply Australian National Coding Standards to code highly complex medical records in an extensive casemix

Complete coding of an average of four highly complex medical records per hour

Enter data to at least 80%accuracy from highly complex medical records

Identify coding issues and conduct research using appropriate materials/resources and or clinical input to generate solutions

Identify sequencing requirements in varied and complex medical records

Identify, interpret and apply necessary amendments to data collection and coding activities

Research and secure information to manage coding questions and complications

Use appropriate resources to assist with highly complex clinical coding requirements

Use manual or an interfaced computerised coding system to submit data or disease index

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