Unit of competency Outline

Date retreived
23/07/2026 10:14 AM AWST

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Undertake a clinical coding audit

Undertake a clinical coding audit

Unit of competency
National Code
HLTCCD009
State Code
ODI89
TGA Status
Current
DTWD Status
Approved
Current Release Number
2.00
Current Release Date
02/07/2021
View on TGA
State Implementation and Classification
Approved Date
29/10/2021
Field of Education
080313 - Public And Health Care Administration
Original Release Date
29/10/2021
Nominal Hours
70
Description
This unit describes the performance outcomes, skills and knowledge to conduct a clinical coding audit and evaluate and validate existing clinically coded data.This unit applies to highly experienced clinical coders who have the ability to interpret a wide range of highly complex clinical coded data and to conduct clinical coding audits. Work may be performed as an individual or as part of team under limited supervision.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian standards and industry codes of practice.No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.
Notes
Elements and Performance Criteria
1. Prepare for internal and external audits.
  • 1.1. Determine objectives, scope and criteria of internal and external audits according to workplace requirements.
  • 1.2. Identify audit methodology and resources for an audit plan.
  • 1.3. Identify and gather policies and procedures and workplace documentation needed for audit.
  • 1.4. Conduct entry meeting with audit parties and explain audit process.
  • 1.5. Determine dispute resolution processes.
2. Validate clinical coding data.
  • 2.1. Identify and arrange access to sample records to be audited.
  • 2.2. Review and evaluate coded data according to audit methodology and record findings using audit tool.
  • 2.3. Evaluate appropriateness of the assigned Diagnosis Related Group (DRG).
  • 2.4. Allocate data discrepancies to relevant error categories.
3. Review audit outcomes.
  • 3.1. Participate in formal and informal meetings to address any data discrepancies, error classifications and documentation issues according to organisational policies and procedures.
  • 3.2. Raise documentation and classification queries with health care information personnel or clinicians according to organisational policies and procedures.
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State Code National Code Title Type
AE573 HLTSS00071 Clinical Coding Auditor Skill Set Skill set