About Clinical Coders’ Society of Australia

CCSA Member Code of Ethics

The Code of Ethics and Practice Standards have been developed to define the principles governing the conduct of CCSA members. 

Every member of the Clinical Coders’ Society of Australia shall abide by the Code of Ethics and Practice Standards, and shall strive to promote the objectives of the Clinical Coders’ Society of Australia at all times.

Members of the Clinical Coders’ Society of Australia shall:

1. Not misrepresent or falsify their education, qualifications or experience, and not make determinations outside their realm of knowledge.
2. Refuse to participate in illegal or unethical acts and will report the illegal or unethical acts of others to the appropriate authorities.
3. Legitimately optimise coding (ensuring all codes assigned accurately reflect care required and provided) but will not maximise coding (add or alter codes which are not substantiated by documentation). 
4. Assist managers and clinicians in guidelines and practices that support ethical coding.
5. Protect the confidentiality of health records and administrative records of health institutions in accordance with legal and management policy requirements unless compelled to do otherwise by statutory requirements.
6. Participate in ongoing education in order to maintain and improve coding competence and support the objectives of the Clinical Coders’ Society of Australia.
7. Liaise with other professional bodies in order to strive for the advancement of quality health care.
8. Discharge honorably the responsibilities of any national or local association positions and preserve the confidentiality of any privileged information obtained whilst acting in an official capacity. 
9. Maintain the integrity of the Clinical Coders’ Society of Australia and not make unsanctioned representations on behalf of the Society.

CCSA Member Practice Standards

Members of the Clinical Coders’ Society of Australia will strive to observe and abide by the following practice standards:

1. In order to assign codes for a particular episode of care or encounter, carry out a thorough review of documentation in the clinical record pertinent to that episode of care.
2. Use documentation in that episode of care or encounter to support the abstraction of diagnoses and interventions.
3. Use definitions of the National Health Data Dictionary to select, code and sequence diagnoses and interventions.
4. Use their skills and knowledge of the current Australian coding system, the Australian Coding Standards and any other available resources, including clinician consultation, to select, sequence and code diagnoses and inventions.
5. Not code diagnoses or interventions that are not substantiated by documentation within the medical record.
6. Initiate and maintain communication with other health care professionals and relevant organisations to improve the quality of documentation and accuracy of coding.
7. Participate in quality improvement activities to ensure the quality of coding is maintained.
8. Ensure coding accuracy is maintained in accordance with work experience accuracy rates.

CCSA Position Statement – Role and duties of the Clinical Coder

Core Role of the Clinical Coder

The role of the Clinical Coder is to assign codes for conditions (including certain health status and circumstances of injury and poisoning) and health interventions, in accordance with recognised classifications and associated directives, that have been documented by clinicians in relation to patient health care events.

Currently, the majority of Clinical Coders assign codes for admitted patient episodes using:

• the International Statistical Classification of Diseases and Health Related Problems, Tenth Revision, Australian Modification (ICD-10-AM);
• the Australian Classification of Health Interventions (ACHI); and
• the Australian Coding Standards (ACS).

These coded data are relied upon for analysis that informs: patient safety; health research; health care funding and resource planning at Commonwealth, State and hospital levels.

Duties Inherent to Clinical Coding

In accordance with Australian Coding Standards, Clinical Coders are expected to analyse all areas of the clinical record relevant to the episode of care and seek clinical clarification regarding any areas that are unclear or where more information is required prior to code assignment.

Once codes have been assigned, Clinical Coders can be expected to enter these codes into the hospital’s patient administration system and ensure that an Australian Refined Diagnosis Related Groups (AR-DRG) is allocated.

Clinical Coders are responsible for the quality of the coded data that they produce and can be expected to:

• maintain expertise in the Casemix that they are normally expected to code and where possible, participate in any fully funded hospital, State or Commonwealth professional development that is offered; and
• undertake checks and actively participate in any other quality assurance processes in relation to their work.

The Clinical Coders’ Society of Australia (CCSA) has an expectation that employers will support and facilitate Clinical Coders’ role by:

• providing access to consistent and complete clinical information and information systems for every episode of care to be coded;
• providing an environment where the Clinical Coder is able to seek more information from the treating Clinician(s) as reasonably necessary, in relation to the episode of care being coded; and
• ensuring reasonable access to fully funded coding education including that which has been endorsed by Commonwealth or State Health Departments.

Where this does not occur, the CCSA considers that the Hospital (not the Clinical Coder) is responsible for the quality of the coded data produced.

Supplementary Clinical Coder Duties

Because Clinical Coders have a certain degree of medical knowledge and read through all parts of the clinical record relevant to the episode of care being coded, they are well suited to performing a number of other tasks that the hospital may require. These may include, but are not limited to:

• reporting already documented information such as:
• intensive care unit (ICU) hours and hours of mechanical ventilation (HMV)
• mental health legal status
• cancer registry reporting
• collection of clinical and other quality indicators.

The CCSA acknowledges and respects the right employers have to require employees to undertake any specific duties within their relevant industrial award and enterprise bargaining agreement (e.g. other administrative tasks). However the CCSA considers that any requirement beyond the core role and inherent duties of a Clinical Coder, should be made clear to the Clinical Coder prior to their employment. Where this is not possible, e.g. there is reorganisation or the task is new, the CCSA considers that a genuine consultation process should occur between the employer and the Clinical Coder.

Advanced/Senior Clinical Coder Duties

Experienced Clinical Coders may have certain additional roles and duties. These include, but are not limited to:

• providing education for other clinical coders in the hospital or health area service
• providing education on clinical coding for Clinicians
• being a specific liaison contact between other Clinical Coders and Clinicians
• being a specific liaison for hospital clinical research, Casemix analysis and/or other Management staff to provide data that best suit their data request requirements
• conducting coding and other related audits
• managing a team of Clinical Coders.

The CCSA considers that these are higher level duties that would normally be undertaken by an advanced/senior Clinical Coder and be remunerated at a higher level than core Clinical Coder duties.

The CCSA welcomes questions about the role of Clinical Coder and the work that they do. For any further information please contact one of our Management Committee Members.