Unit of competency Outline

Date retreived
22/07/2026 12:12 PM AWST

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Undertake complex clinical coding

Undertake complex clinical coding

Unit of competency
National Code
HLTADM006
State Code
AVB13
TGA Status
Replaced
DTWD Status
Transition (Replaced)
Current Release Number
1.00
Current Release Date
06/08/2015
View on TGA
State Implementation and Classification
Approved Date
22/01/2016
Field of Education
010103 - Statistics
Original Release Date
22/01/2016
Nominal Hours
20
Description
This unit describes the skills and knowledge required to undertake coding of moderately complex discharge summaries, medical reports and medical records, including the selection of the primary diagnosis and sequencing of other diagnoses for coding.This unit applies to clinical coders. The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Notes
Elements and Performance Criteria
1. Abstract clinical data from moderately complex medical records
  • 1.1 Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex medical records
  • 1.2 Select appropriate conditions/diseases and procedures for coding from moderately complex medical records
  • 1.3 Identify the principal diagnosis and principal procedure for an admission when coding from moderately complex medical records
  • 1.4 Identify additional diagnoses and procedures
  • 1.5 Establish the correct sequencing of diagnoses and procedures
2. Assign codes relating to moderately complex medical records
  • 2.1 Apply ACS where appropriate, to ensure the correct assignment of codes when coding from moderately complex medical records for a range of specialties
  • 2.2 Assign complete and accurate International statistical classification of diseases and related health problems (ICD-10-AM), disease codes and Australian Classification of Health Interventions (ACHI) procedure codes
  • 2.3 Utiliseresources where appropriate to assist in making coding decisions
  • 2.4 Recognise problems relating to privacy and confidentiality of client information
  • 2.5 Maintain confidentiality of medical records and client information at all times
  • 2.6 Complete the process of assigning the correct codes from moderately complex medical records within appropriate timeframes
  • 2.7 Meet work health and safety duty of care requirements
3. Maintain clinical coding records
  • 3.1 Record, enter, edit and maintain a client information system of coded data (disease index)
  • 3.2 Address changes to data collection and coding requirements, according to relevant standards, protocols and legislation
  • 3.3 Make amendments to data collection and coding activities in line with organisation requirements
  • 3.4 Maintain and update own knowledge and skills to ensure that amendments are addressed as required
No information
No information
Replaces
State Code National Code Title Type
D5817 HLTCC401B Undertake complex clinical coding Unit of competency
Replaced By
State Code National Code Title Type
ODI48 HLTCCD007 Undertake moderately complex clinical coding Unit of competency
State Code National Code Title Type
AD181 HLTSS00048 Clinical Coding Skill Set Skill set
AWM1 HLT47315 Certificate IV in Health Administration Qualification