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 and seek clinical clarification regarding any areas that are unclear or where more information is required prior to code assignment (refer to ACS excerpt Attachment A).
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 AR-DRG group 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 the employer will support and facilitate Clinical Coders’ role by:
- providing access to consistent and complete clinical information for every episode to be coded;
- providing an environment where the Clinical coder is able to seek more information from the treating Clinician as reasonably necessary, in relation to the episode being coded; and
- ensuring reasonable access to fully funded coding update 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 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:
- ICU hours and hours of mechanical ventilation
- 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
- 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 codes 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 Clinical Coders and the work that they do. For any further information please contact your CCSA state representative.