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Clinical Coder
Also known as Medical Records Coder.
Clinical coders translate descriptions of medical diagnoses and procedures into codes, which record healthcare data.
Clinical coders work closely with medical staff who are responsible for recording the information required for coding medical data within patients' medical records.
TASKS
- read and analyse medical records to help identify all diagnoses, operations and procedures relevant to the current period of patient care
- clarify inconsistent or non-specific information in a medical record by consulting with the responsible medical practitioner
- allocate codes to patients' current period of care, using knowledge of the information contained within the International Classification of Diseases, 10th Revision Australian Modification, commonly referred to as ICD-10-AM
- conduct assessment of work to ensure there is continuous improvement in ICD-10-AM coding and collection of quality health data
- assess the medical record content and highlight shortcomings to management
- maintain ICD-10-AM coding books to make sure they are updated to the current version being used
- assist with the education of clinical staff with regard to ICD-10-AM
- work with computing and finance staff
- ensure the patient episode is allocated to the correct Diagnosis
- assist with medical research and casemix (patient statistics) projects (DRG)
Clinical coders may perform the following tasks:
PERSONAL REQUIREMENTS
- able to perform precise and detailed work
- able to concentrate for long periods of time
- excellent problem-solving skills
- good communication and interpersonal skills
- able to work as part of a team
- interested in healthcare procedures
- willing to continually update skills and knowledge
Interest Area
EDUCATION & TRAINING
To become a clinical coder you usually have to complete an accredited ICD-10-AM, ACHI and ACS clinical coding course. Entry into these courses requires an 80 per cent pass in the Health Information Management Association of Australia (HIMAA) Comprehensive Medical Terminology course or the HIMAA Challenge Examination in Medical Terminology. There are no specific prerequisites for these courses.
Additional Information
To achieve HIMAA Clinical Coder Certification, candidates must successfully complete further advanced training (which requires appropriate clinical coding experience) and pass an advanced coding examination.
EMPLOYMENT OPPORTUNITIES
Clinical coders work mainly in public and private hospitals. Roles vary depending on the size and type of services offered. 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.
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