Pink Cockatoo
Ready
for
the
next
session?
© 2014
‹#›
PREPARED BY: ANNA COOTE & HEATHER GRAIN
CLINICAL CODER TRAINING
EXPECTATIONS
Objective
Understanding
of:
•
Clinical
Coding
skills
•
Clinical
Coder
training
•
Different
needs
for
different
types
of
organization
•
Clinical
Coder
career
structure
© 2014
‹#›
Skills
needed
for
clinical
coding
• Understand medical words and medical practice • Medical vocabulary
• Medical science • Apply coding conventions
• Apply coding standards for code system
• Find and assess relevant health record content • Use and apply systems in organisations
• Attention to detail
• Abstracting from records and assigning the correct code.
Australian
Government
accredited
training
•
The
Australian
Skills
Quality
Authority
(ASQA)
is
the
national
regulator
for
Australia’s
vocational
education
and
training
sector
.© 2014
‹#›
RTO
– Registered
Training
Organization
• RTO – registered training organization.
• A training provider registered by ASQA to deliver VET services.
• Delivery courses recognized and accredited by the Australian Qualifications Framework
(AQF)
• Recognized as providers of quality assured and nationally recognized training and qualifications.
RTO*
ICD
‐
10
‐
AM
Training
Available
•
eHealth
Education
•
OTEN
•
HIMAA
•
Curtin
University
•
Latrobe
University
*RTO – registered training organization.
A training provider registered to deliver VET services.
© 2014
‹#›
Levels
of
Clinical
Coding
Skill
•
Basic
•
Intermediate
•
Advanced
•
Auditor
•
Administration
WORKPLACE
FOR
a
Basic
Clinical
Coder
•
Day
surgery
centre
•
Endoscopy
•
Dental
•
Ophthalmology
•
Mixture
of
above
•
Hospitals
with
day
stay
type
cases
•
Hospitals
with
a
Coding
Educator
© 2014
‹#›
WORKPLACE
for
an
Intermediate
Clinical
Coder
Hospitals with records of patients admitted for between 2 and 5 days,
AND for
• a medical condition (with or without) complications; or
• surgery of at least 1 hour in Operating Theatre; or • surgery followed by complications (stated to be
postoperative or not); or
WORKPLACE
FOR
an
Advanced
Clinical
Coder
• Fully competent with coding standards • Fluent in medical vocabulary
• Competent at understanding(or, if not, ‐researching)
• medical conditions, • signs,
• symptoms,
• procedures and treatments.
• Confidently find and communicate with all levels of clinical hierarchy on clinical coding issues
• Training / mentoring skills
© 2014
‹#›
Skills
for
different
functions
SKILLS
‐
Basic Clinical
Coder
Sufficient
level
for
Day
Only
Clinical
Coding:
•
Medical
vocabulary
•
Medical
science
Full
competency
with:
•
Coding
conventions
•
Relevant
Coding
Standards
•
Record
content
at
Day
Stay
level
•
Systems
in
health
care
at
Day
Stay
level
© 2014
‹#›
SKILLS
‐
Intermediate
Clinical
Coder
• More complicated, longer stay cases:
• larger medical vocabulary
• larger Medical Science knowledge
• ability to research and find information alone, within
the organization (self‐directed learning).
• Extend knowledge of Coding Standards
• Abstract information from all types of clinical
documentation available. Search for detail
• not in the Discharge Summary
• in related computer systems (PACS)
• Understand and interpret more complicated Operation
Reports
• Coding of medical and surgical complications
SKILLS
‐
Advanced
Clinical
Coder
• Fully competent with coding standards • Fluent in medical vocabulary
• Competent at understanding(or, if not, ‐researching)
• medical conditions, • signs,
• symptoms,
• procedures and treatments.
• Confidently find and communicate with all levels of clinical hierarchy on clinical coding issues
• Training / mentoring skills
© 2014
‹#›
SKILLS
‐
Clinical
Coding
Auditor
• Prerequisites:
• Advanced level coding skills
• Excellent interpersonal and communication skills • Report writing • Training skills WORKPLACE • Government body • Hospital • Private company
Skills
for
different
organisations
(Horses for courses)
© 2014 ‹#›
Hospitals
•
Clinical
coders
•
CC
managers
•
Auditors
•
Data
Manager
•
Casemix manager
•
Coding
educator
SKILLS
‐
Health
Insurance
organisation
•
Clinical
coder
•
Auditor
•
Data
Manager
•
Query
management
•
Casemix management
© 2014 ‹#›SKILLS
‐
National
Health
Management
•
Access
to
Auditors
•
Data
Manager
•
Query
management
Career
Structure
© 2014
‹#›
Career
structure
Based on a combination of: • Qualifications
• Experience • Skills
ASSESSING
CLINICAL
CODER
SKILLS
•
Employment
testing
•
Coding
audits
© 2014 ‹#›Governance
of
Casemix
•
National
coding
meetings
•
National
coding
decisions
&
guidelines
•
Co
‐
ordination
of
National
•
training
•
competency
definition
•
Casemix development
unit
CONCLUSION
•
What
requirements
have
we
identified
for
CCHI
and
KSA?
•
What
are
the
major
gaps?
•
What
are
the
priorities?
© 2014
‹#›
The
Next
Workshop
•
What
does
a
coder
do?
•
How
do
they
do
it?
•
What
is
their
training/background?
•
How
are
they
managed?
•
Where
do
they
fit
in
the
health
Clinical
Coder
Job
Description
© 2014
‹#›
Job
description
template
•Title: full time trainee clinical coder at 200 bed hospital with all medical and surgical specialties
•Responsible to:
•Subordinates (if any): •General description
•Responsibilities: 1. 2. 3. etc. •Required experience (if any) •Required qualifications (if any) •Other:
Where
are
you
at?
•Have you identified staff who could become your Clinical Coders?
•Have you identified a training package that you can use to train your Clinical Coding Staff?
•Have you found a place for a Clinical Coder in your Organizational Chart?
•And finally … do you have a job description for a Clinical Coder in your organization?
© 2014
‹#›
