Clinical Coder

What is a Clinical Coder

Clinical coders translate diagnoses and procedures documented in the medical record into codes. This data is used for a variety of purposes including funding, planning, research, disease surveillance and quality activities.

Roles of a Clinical Coder

• Read and analyse information contained in medical records to identify diagnoses and procedures relevant to an  episode of patient care
• Assign codes using the International Classification of Diseases, 10th Revision, Australian Modifications (ICD-10-AM), Australian Classification of Health Interventions (ACHI) and the Australian Coding Standards (ACS)
• Clarify inconsistent, unclear or non-specific information in a medical record by consulting with the relevant  clinical staff 
• Participate in quality improvement activities to ensure codes assigned accurately reflect the clinical care provided during an episode of care 
• Participate in ongoing education sessions and remain informed of National Coding Advice and Australian Coding Standards
• Assist with the education of clinical staff with regard to clinical coding
• Liaise with various hospital staff
• Assist with medical research and casemix projects

Career Opportunities

Clinical coders work mainly in public and private hospitals. Roles vary depending on the size and type of services offered by the individual facility/hospital. For example, a coder in a country regional area may be responsible for the production of data for a number of hospitals, involving travel to each. In larger institutions the role of the coder may also include supervision of coding staff, data analysis and education. Coders may also work in specialist research and clinical units and for health insurance funds.

Qualifications Required

To become a clinical coder it is necessary to complete an accredited ICD-10-AM coding course.
Clinical coding courses are offered by the following institutions:

• Health Information Management Association of Australia (HIMAA)
  HIMAA offers an Introductory ICD-10-AM, ACHI and ACS coding course. Entry to this course requires an 80% pass mark in the HIMAA Comprehensive Medical Terminology course or the HIMAA Challenge exam in Medical Terminology

• TAFE
  OTEN Medical Records Coding Course

Supervision required

A comprehensive orientation program is provided for all new staff members with ongoing support.

Personal skills required of a Clinical Coder

• Good attention to detail and analytical skills
• Good communication and interpersonal skills
• Able to work independently and as part of a team
• Interest in health care procedures
• Willingness to continually update skills and knowledge.
   

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