HLTCCD006 - Undertake basic clinical coding

Unit code:HLTCCD006Study level:TAFE

Nominal hours

120

Location

Online

Prerequisites

HLTCCD005 - Abstract information for clinical coding
(Or equivalent to be determined by unit coordinator)
Co-requisites
(Corequisite units must be studied concurrently with this unit)

Overview

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 basic patient health care records.This unit applies to clinical coders who are responsible for understanding and extracting patient clinical information for the purposes of clinical coding.

Assessment

For Melbourne campuses

Assessment tasks will be designed to reinforce & extend knowledge and skill competence within set & controlled parameters in accordance with each units learning outcomes & performance criteria requirements, including the setting of work based practical application tasks designed to provide evidence of competence outcomes, within periodic and scheduled timelines.

Students will be expected to demonstrate the following required skills:

use current coding manuals and standards to produce coded clinical data from basic patient health care records for at least ten episodes of care for each of the following:

infectious and parasitic diseases
neoplasms
diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
endocrine, nutritional and metabolic diseases
mental and behavioural disorders
diseases of the nervous system
diseases of the eye and adnexa
diseases of the ear and mastoid process
diseases of the circulatory system
diseases of the respiratory system
diseases of the digestive system
diseases of the skin and subcutaneous tissue
diseases of the musculoskeletal system and connective tissue
diseases of the genitourinary system
pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
injury, poisoning and causes of morbidity and mortality

for each of the above, use reference materials to inform code assignment for unfamiliar clinical concepts
for the above, episodes of care should collectively include the following:

same-day episodes of care cases
minor injuries
basic surgeries
overnight episodes of care
both acute and chronic forms of a disease or condition.

Students will also be expected to demonstrate the following knowledge:

definition of a clinical coder and clinical coding, and the purpose of coded clinical data
codes of practice and guidelines in relation to clinical coding, including professional ethics
Australian and State/Territory clinical coding standards and protocols
rules and conventions applied to clinical data and relevant to coding
sequencing protocols for clinical coding, including those for principal, additional diagnoses and interventions
timescales within which clinical coding must take place
key performance indicators (KPI’s) and quality indicators for coded clinical data
classifications and nomenclature relevant to clinical coding
coding classifications, standards and conventions for:

infectious and parasitic diseases
neoplasms
diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
endocrine, nutritional and metabolic diseases
mental and behavioural disorders
diseases of the nervous system
diseases of the eye and adnexa
diseases of the ear and mastoid process
diseases of the circulatory system
diseases of the respiratory system
diseases of the digestive system
diseases of the skin and subcutaneous tissue
diseases of the musculoskeletal system and connective tissue
diseases of the genitourinary system
pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
injury, poisoning and causes of morbidity and mortality.

Required reading

The qualified trainer and assessor will provide teaching and learning materials as required in the form of workbooks produced by Victoria University and/or via the Victoria University e-learning system.