What is Clinical Coding?

Clinical coding is the process of translating health records into standardised alphanumeric codes. These codes are then used for state and commonwealth data reporting, health service planning and hospital funding models.

Coding of health data has been undertaken in Australian hospitals since the late 1940s, and currently the ICD-10-AM (Twelth Edition), Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS) represents the classification system used to code all admitted patient episodes of care nationally.

A medical record often contains a wealth of important health data including descriptions of diseases, injuries and procedures. However, this information is typically (hand) written in narrative form, and therefore requires a qualified clinical coder to analyse the record and translate the descriptions into standardised alphanumeric codes.

For example, if the medical record states,

The patient was admitted for deep brain stimulation for Parkinson’s disease

This would be represented by;

Unfortunately, a clinician’s description of a disease, injury or procedure can sometimes be ambiguous and open to interpretation. This can often lead to incorrect coding and a loss of eligible funding for the doctor, hospital and patient. Therefore, it is important that all clinicians clearly document their patient encounters using only commonly accepted abbreviations and terminology.

There is a recognised shortfall in the coding workforce of Australia, as has been articulated by multiple national surveys including those by HIMAA, McKenzie & Walker and the Australian Institute of Health and Welfare.

The Australian health system is under increasing pressure to deliver adequate levels of quality services to meet the needs of the population. This pressure is driven by increasing demand due to an ageing population, rising chronic disease, advancing technology and pressures associated with workforce shortages*.

Clinical coders are primarily responsible for translating health records into alphanumeric codes according to the relevant classifications. They work mainly in public and private hospitals, however some work in specialist research roles or for health insurance funds. Some of the key responsibilities of a successful clinical coder includes;

We analysed over 50 job ads across Seek, indeed and CareerOne, and found that the overwhelming majority of clinical coding employers require you to have a nationally recognised qualification.

Coding complex medical records often requires you to have a broad set of skills and knowledge including;

Up until recently, many clinical coders were required to undertake a typical 3-year degree in Health Information Management. However, in response to growing industry demand and employer requirements for clinical coders, the Australian government commissioned the HLT50321 Diploma of Clinical Coding.

Designed to teach you medical coding from the ground up, TalentMed’s HLT50321 Diploma of Clinical Coding is your first step towards becoming a successful clinical coder.

This qualification aims to reflect the role of an entry-level clinical coder, who uses the range of skills and knowledge listed above, to analyse and code medical records. Some of the key benefits of this course includes;

If you would like more information on how you can start training to become a qualified clinical coder, request a free information pack below.