Clinical coder

Reference Number: ST0535

Details of standard

Occupational profile

Clinical coding is the process of translating medical information from patient records in hospitals, into alphanumeric codes. A Clinical Coder will spend time reading medical notes / records and analysing the contents which they then translate into alphanumeric codes that accurately represent the patient’s stay. Clinical Coders locate missing information by whatever process necessary including contacting Medical Secretaries or by pulling case notes and requesting diagnoses from clinical staff where appropriate. They input Clinical Codes onto the Patient Administration Systems, action outstanding clinical coding reports as required (including, bringing them to the attention of the appropriate team members, and senior Clinical Coding colleagues and/or manager(s) when necessary), as well as dealing with any queries or taking messages for the staff within the Clinical Coding Department, including data quality issues, bringing to the attention of senior Clinical Coding colleagues and/or manager(s) any problems encountered or any issues, affecting the Clinical Coding.

Every NHS Hospital in the UK and private healthcare companies has a Clinical Coding Team who are required to meet the NHS Digital Clinical Classifications Service and the World Health Organisation (WHO) requirements and national deadline. The codes are used in a variety of ways within Hospitals, such as:

• Determining the payment required for patients seen or treated.
• Clinically monitor and manage the care provided to patients, for example the frequency occurrence of a patient’s condition or how many patients have died and why.
• Statistical use of the data by NHS Managers for beds, staffing and waiting list management and health trends.

The responsibilities and duties of the role are to abstract, analyse, translate medical terminology as written by the clinician and assign classification codes obtained from International Statistical Classification of Diseases (ICD) and related health problems for diagnoses and/or Office of Population, Censuses and Surveys of Surgical Operations, Interventions and Procedures (OPCS) in accordance with National and International Coding Standards, and guidelines, following complex rules and conventions of the diagnosis and procedure classification frameworks. Provide accurate and timely allocation of diagnostic and procedure codes for clinical and management purposes, including funding, commissioning, research, benchmarking and audit. Deal with enquiries from clinical, administrative and management staff; liaising with clinical teams, and locating and collating missing clinical data, e.g. case notes, histopathology and investigation results, for clinical coding.

Responsibilities and day to day duties of the role:

• Assess patient records and notes content
• Identify and apply medical terminology terms into code
• Allocate diagnosis and procedural codes to patients records
• Extract information from all types of clinical documentation and assess relevant health record content
• Input clinical codes onto Patient Administration Systems
• Work under pressure to local financial deadlines
• Communicate with a wide range of stakeholders to gather and share information
• Undertake background research as necessary
• Identify data quality issues and take appropriate action

Clinical Coders work as part of a team and provide support to senior colleagues, which, depending on the makeup of the specific department, could be one or more of the following: Senior Clinical Coder, Clinical Coding Team Leader, Clinical Coding Supervisor, Clinical Coding Trainer, Clinical Coding Auditor, Clinical Coding Assistant Manager, Clinical Coding Manager. This typical team structure also provides progression opportunities for those wishing to build a career in clinical coding.

Entry Requirements

Individual employers will set selection criteria. This might include Level 2 in English Language, Mathematics and a Science subject (preferable Science / Biology

Qualification requirements

Apprentices without level 2 English and maths will need to achieve this level prior to completing the end-point assessment. For those with an education, health and care plan or a legacy statement the apprenticeships English and maths minimum requirement is Entry Level 3 and British Sign Language qualification are an alternative to English qualifications for whom this is their primary language.

Values

• Respect – respect each other at all times with regard to age, disability, gender, position, race, religion and sexual orientation through professionalism and courtesy, treating all patients, colleagues, visitors, carers, communities and others as they would wish to be treated
• Responsibility – personal and collective responsibility to do the best we can, working towards agreed individual and Trust-wide goals and expect to be held accountable and to challenge poor performance
• Honest – open, have integrity
• Selflessness – they should not take decisions to gain financial or other material benefits for the organisation

Behaviours

• Agile & Flexible – being tenacious and driven to see projects through to completion. A proven self-starter and have an adaptable approach to meet changing work priorities.
• Professionalism & emotional intelligence – a high level of professionalism, reliable and dependable, collaborative approach and show empathy and being mindful of others
• Has a desire to learn and a thirst for knowledge and a willingness to learn from mistakes
• Shows emotional maturity – Ability to deal with direct exposure to disturbing photographs and case notes, potentially regarding abuse and terminally ill patients. There may be instances where you may be needed to attend a hospital ward where you may witness disturbing scenes
• Adaptive to environment, working in both an office and busy healthcare environment

Level: 3

Duration: typically 18-24 months

Review Date: after 3 years

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