92033 Health Classification and Terminologies A
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particular session, location and mode of offering is the authoritative source
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Subject handbook information prior to 2025 is available in the Archives.
Credit points: 6 cp
Subject level:
Postgraduate
Result type: Grade and marksRequisite(s): 96202 Language of Healthcare
Description
Health information services provide a range of important services, none more so than clinical classification (also referred to as 'clinical coding'). Clinical classification is one of the key discipline specific tasks undertaken by health information managers, hence the need to ensure that graduates have successfully completed an industry-recognised training program.
This subject is designed to equip students with the foundational skills to understand the coding process, interpret clinical documentation contained in source data, and to accurately select and assign ICD-10-AM/ACHI codes using the conventions and rules set out in the Australian Coding Standards (ACS).
This is the first subject of a two-part subject combination (the second is 92034 Clinical Classification and Terminologies B). To undertake both subjects, it is imperative that students draw upon their knowledge of medical terminology, anatomy and physiology gained in 96202 The Language of Healthcare.
Subject learning objectives (SLOs)
| A. | Extract, analyse and report on coded data using legacy classification systems/indices [Appl] |
|---|---|
| B. | Accurately assign and justify diagnosis and procedure codes using mandated health classification systems, current Australian coding standards, health data definitions, jurisdiction admission/care type policies and business rules [Eval] |
| C. | Evaluate healthcare record content, applying knowledge of medical vocabulary, anatomy and physiology, diagnostics and interventions to abstract relevant data for clinical coding [Eval] |
| D. | Review assigned sets of diagnosis and procedure codes, and resultant DRG, to ensure fair and optimal representation of the health care encounter [Eval] |
| E. | Identify and address discrepancies in documentation affecting code allocation [Eval] |
Course intended learning outcomes (CILOs)
This subject also contributes specifically to the following graduate attributes:
- Are reflective, critical thinkers who influence practice, policy and research to achieve clinical excellence and transform healthcare services (1.0)
- Critique, interpret and synthesise data and research findings to develop safe, effective and evidence-based solutions to healthcare challenges (1.1)
- Initiate and explain change management methodologies appropriate to improving healthcare outcomes (1.3)
- Effective, collaborative and responsive leader who considers health care in a global context (2.0)
- Justify and demonstrate appropriate leadership styles and skills necessary to manage, evaluate and innovate healthcare services utilising contemporary local, national and international perspectives (2.1)
- Communicate effectively and appropriately in challenging, complex and diverse situations (4.0)
Contribution to the development of graduate attributes
1. Critical thinking:
1.1 Critique, interpret and synthesise data and research findings to develop safe, effective and evidence-based solutions to healthcare challenges
2. Leadership:
2.2 Develop and contribute to research and quality improvement activities in order to maintain knowledge currency and influence healthcare practice and policy
3. Accountability:
3.2 Validate the importance of integrating stakeholder partnerships in all healthcare decision making activities
4. Communication:
4.1 Value and choose highly effective and sensitive communication with diverse populations to enable positive and sustainable change in healthcare practice, policy and research at an advanced level
Teaching and learning strategies
Pre-session learning
Students access online learning resources prior to attending face-to-face on-campus sessions to improve their confidence in approaching the proposed content, afford them time to construct questions, and facilitate discussion in class, resulting in shared learning, experiences and reflections. The specific sessions will be detailed in this subject outline and all resources will be located on Canvas.
Blend of online and face-to-face strategies
This subject benefits from both the real time delivery of content and access to resources via Canvas. The workshops provide a variety of collaborative activities for each content area. Students will learn theoretical concepts relating to clinical classification and the application of clinical coding skills to case based examples.
Case based scenarios and collaboration
Case scenarios, discharge summaries and simulated medical records will provide the basis for an inquiry-based approach to problem solving. Students will collaborate and use these resources to learn concepts and skills in data abstraction, code assignment, and case complexity, as well as gaining insight into the impact clinical document has on clinical care and the coding process. Self, peer and teacher feedback is provided during the sessions to develop students’ learning and judgement.
Assessment range
Students will be exposed to a variety of assessment modes, including reports, presentations, and online quizzes and examination.
The online quizzes and the online examination represent the bulk of marks for this subject given that students must be able to demonstrate competency and accuracy in the allocation of clinical codes, which are the essential pre-requisite underpinning hospital funding nationwide. Thus in line with industry standards, the pass mark for each quiz and the final examination is set at 80% to reflect the importance of high quality coding for the health sector. Students will be given two opportunities to achieve this mark on assessment task 4.
Early low-stakes feedback will be provided via two methods:
- during the on-campus sessions, where students discuss material raised in the sessions, and ask questions of their peers and lecturing staff;
- results for online coding quizzes 1, 2 and 3 to be provided in weeks 3 – 5; assessment task 2, worth 15%, will be received prior to the census date.
Continual feedback will be provided via methods:
- peer communication, individual and lecturing staff contributions to the session discussions;
- assessment tasks, worth 15%, 25%, 10% and 50%.
Content (topics)
- Principles of data abstraction and code assignment
- Health Classification Systems
- Coding diseases with ICD-10-AM
- Coding procedures with ACHI
- Australian Coding Standards and coding rules and conventions
- Coding symptoms, factors influencing health status and infectious diseases
- Coding neoplasms
- Coding blood, endocrine and mental disorders
- Coding nervous system, eye, ear, nose and mouth disease
- Coding circulatory diseases
- Coding respiratory, digestive and hepatobiliary system and skin diseases
- Coding musculoskeletal and genitourinary diseases
Assessment
Assessment task 1: Online challenge quizzes
| Intent: | Clinical classification is a skill that is enhanced by application and practice. The purpose of this formative assessment task is to develop student’s coding skills by undertaking online challenge quizzes that address the content covered in the preceding workshop. The questions set in the challenge quizzes will form the basis of the content assessed in the final online coding examination i.e. assessment task 4. Each quiz will provide an opportunity for students to practice their abstraction and assignment skills and to receive feedback on their performance. If students achieve an 80% pass on the quiz they will be awarded 1 mark; there are 10 quizzes in total, so potential for a total of 10 marks to be accrued. |
|---|---|
| Objective(s): | This assessment task addresses subject learning objective(s): B and C This assessment task contributes to the development of graduate attribute(s): 1.1 and 2.1 |
| Type: | Quiz/test |
| Groupwork: | Individual |
| Weight: | 10% |
| Length: | Each quiz is restricted to 30 minutes. |
| Criteria: |
|
Assessment task 2: Alternative Classification Systems
| Intent: | While the vast majority of clinical coding takes place in the acute care setting, it is important to be aware that this activity also takes place in a range of facilities across the health continuum using classification systems that differ from ICD. The purpose of this assessment task is for students to investigate alternative classification systems utilised internationally throughout different practice settings. |
|---|---|
| Objective(s): | This assessment task addresses subject learning objective(s): C and E This assessment task contributes to the development of graduate attribute(s): 1.0, 1.1, 1.3 and 4.0 |
| Type: | Report |
| Groupwork: | Individual |
| Weight: | 15% |
| Length: | 750 words |
| Criteria: |
|
Assessment task 3: Communicating the relationship between documentation and clinical classification
| Intent: | Clinical classification relies upon complete and accurate source data. Clinicians (doctors, nurses and allied health professionals) are responsible for documenting the care they provide to their patients. If this documentation is incomplete, erroneous, illegible or unverified it can impact directly on the care process and consequently on clinical classification. Developing staff orientation material addressing these matters, as well as effectively communicating these requirements are key functions of Health Information Managers. |
|---|---|
| Objective(s): | This assessment task addresses subject learning objective(s): C, D and E This assessment task contributes to the development of graduate attribute(s): 1.3, 2.0, 2.1 and 4.0 |
| Type: | Presentation |
| Groupwork: | Individual |
| Weight: | 25% |
| Length: | 10 minutes |
| Criteria: |
|
Assessment task 4: Final take home exercise
| Intent: | This assessment task aims to ensure students are competent in accurately assigning and justifying diagnosis codes using ICD 10–AM, procedure codes using ACHI and in applying the rules of the Australian Coding Standards. |
|---|---|
| Objective(s): | This assessment task addresses subject learning objective(s): B and C This assessment task contributes to the development of graduate attribute(s): 1.1 and 2.1 |
| Type: | Exercises |
| Groupwork: | Individual |
| Weight: | 50% |
| Length: | Maximum 3 hours in duration |
| Criteria: |
|
Required texts
Australian Consortium for Classification Development. (2019). The International Statistical Classification Of Diseases And Related Health Problems, Eleventh Revision, Australian Modification (ICD-10-AM/ACHI/ACS) (11th ed.). Darlinghurst, NSW: Independent Hospital Pricing Authority.
Australian Consortium for Classification Development. (2019). The Australian Classification of Health Interventions (11th ed.). Darlinghurst, NSW: Independent Hospital Pricing Authority.
Australian Consortium for Classification Development. (2019). The Australian Coding Standards (11th ed.). Darlinghurst, NSW: Independent Hospital Pricing Authority.
The required references above may be purchased as a set of five hard copy books or as an eBook version comprising all five volumes. You will need to obtain one of these versions of the classifications i.e. either the set of hard copy books or one of the eBook versions (Codexpert or TurboCoder). You will need to have your student identification number available to obtain copies at the student prices.
Note that smart phone versions are not acceptable for use in 92033.
How to obtain the classifications:
- Hard copies of the classifications are available from the Independent Hospital Pricing Authority AR-DRG Classification System Product Sales website at: http://ar-drg.laneprint.com.au/
- Codexpert: https://pavilion-health.com/codexpert_pricing/
- TurboCoder: https://www.ecompress.com/buyICD10AMs10th.htm
Use the promotional code: EDUPRICE10TH to get the 30% student discount.
Recommended texts
Harris, P., Nagy, S., and Vardaxis N. (Eds.). (2018). Mosby's dictionary of medicine, nursing and health professions. (Revised 3rd Australian and New Zealand Edition). Chatswood, NSW: Elsevier, Australia. ISBN: 9780729542807. Available as a hard copy or eBook publication at: ebook - Mosby's dictionary of medicine, nursing and health professions
HIMAA (2017). The Australian dictionary of clinical abreviations, acronyms and symbols (7th edition). Sydney: HIMAA. ISBN 978-0-9946206-3-7 Available at: www.himaa.org.au as a hard copy book or app for iOS or Anroid products.
Other resources
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Improve your academic and English language skills
Marks for all assessment tasks such as assignments and examinations are given not only for what you write but also for how you write. If you would like the opportunity to improve your academic and English language skills, make an appointment with the HELPS (Higher Education Language & Presentation Support) Service in Student Services.
HELPS (Higher Education Language & Presentation Support)
HELPS provides assistance with English language proficiency and academic language. Students who need to develop their written and/or spoken English should make use of the free services offered by HELPS, including academic language workshops, vacation intensive courses, drop-in consultations, individual appointments and Conversations@UTS (www.ssu.uts.edu.au/helps). HELPS staff are also available for drop-in consultations at the UTS Library. Phone (02) 9514 9733.
Please see www.uts.edu.au for additional information on other resources provided to students by UTS.