CLINICAL CODER TRAINING EXPECTATIONS RESPONSIBILITIES

Transcription

1 Ready for the next session? Pink Cockatoo CLINICAL CODER TRAINING EXPECTATIONS RESPONSIBILITIES PREPARED BY: ANNA COOTE & HEATHER GRAIN 1

2 Objective Understanding of: Clinical Coding skills Clinical Coder training Different needs for different types of organization Clinical Coder career structure 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. 2

3 Australian Government accredited training The Australian Skills Quality Authority (ASQA) is the national regulator for Australia s vocational education and training sector. 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. 3

4 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. Levels of Clinical Coding Skill Basic Intermediate Advanced Auditor Administration Data Extraction and management 4

5 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 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 chronic, or multiple medical, conditions. 5

6 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 Skills for different functions (Horses for courses) 6

7 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 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 Able to differentiate between symptoms and conditions 7

8 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 SKILLS Clinical Coding Auditor Prerequisites: Advanced level coding skills Excellent interpersonal and communication skills Report writing Training skills WORKPLACE Government body Hospital Private company 8

9 Skills for different organisations (Horses for courses) Hospitals Clinical coders CC managers Auditors Data Manager Casemix manager Coding educator 9

10 SKILLS Health Insurance organisation Clinical coder Auditor Data Manager Query management Casemix management SKILLS National Health Management Access to Auditors Data Manager Query management Casemix management 10

11 Career Structure Career structure Based on a combination of: Qualifications Experience Skills Interests 11

12 ASSESSING CLINICAL CODER SKILLS Employment testing Coding audits Governance of Casemix National coding meetings National coding decisions & guidelines Co ordination of National training competency definition Casemix development unit National coding audits 12

13 CONCLUSION What requirements have we identified for CCHI and KSA? What are the major gaps? What are the priorities? 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 system? 13

14 Clinical Coder Job Description 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: etc. Required experience (if any) Required qualifications (if any) Other: 14

15 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? Time for a break 15