92034 Health Classification and Terminologies B
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Subject handbook information prior to 2025 is available in the Archives.
Credit points: 6 cp
Result type: Grade and marks
Requisite(s): 92033 Health Classification and Terminologies A
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 second subject of a two-part subject combination. The first subject, 92033 Clinical Classification and Terminologies A, exposes students to the process of data abstraction and coding and provides them with foundational skills in clinical classification. 92034 Clinical Classification and Terminologies B, builds these skills further, in particular moving into clinical disciplines that represent more difficult case complexity. This subject also seeks to foster development of student’s skills in managing and resourcing the coding service, as well as ensuring that the framework for competent and ethical professional practice is embedded in their knowledge base. A To undertake both 92033 and 92034 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. | Evaluate healthcare record content, applying knowledge of medical vocabulary, anatomy and physiology, diagnostics and interventions to abstract relevant data for clinical coding [Eval] |
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| 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. | Review assigned sets of diagnosis and procedure codes, and resultant DRG, to ensure fair and optimal representation of the health care encounter [Eval] |
| D. | Analyse, select and implement applications, processes, policies and procedures to ensure accuracy and timeliness of clinical classification and coding [Analy] |
| E. | Integrate principles of quality management to ensure accuracy of coded data, including participation in clinical coding quality activities [Analy] |
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 Blackboard.
Blend of online and face-to-face strategies
This subject benefits from both the real time delivery of content and access to resources via Blackboard. The workshops provide a variety of collaborative activities for each content area. Students will continue to learn theoretical concepts relating to clinical classification and the application of clinical coding skills to case based examples. Electronic applications that support clinical classification and coding will be utilised so that students develop the skills to ensure they are workplace ready.
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 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. Students must pass assessment task 4 to be eligible to pass the subject.
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 quiz 1 to be provided in week 4.
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)
- Coding respiratory, digestive and hepatobiliary system and skin diseases
- Coding musculoskeletal and genitourinary diseases
- Coding pregnancy, childbirth and puerperium
- Coding neonatology
- Coding injury and external causes
- Coding poisoning and external causes
- Coding with the 3M encoder
- Managing the coding service
- Ensuring coding quality
- Coding audits
- Ethical conduct in clinical coding
- Coding instrumentalities (IHPA) and professional associations (CCSA and HIMAA)
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. |
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| Weight: | 10% |
Assessment task 2: Professional Standards and Ethics in Clinical Classification
| Intent: | The Australian Clinical Coding Practice Framework was established to “support national consistency in clinical coding practice and to provide guidance in defining and promoting good practices for those involved in the clinical coding process” (HIMAA, 2019). The purpose of this assessment task is for students to consider the administrative, legal and ethical requirements of clinical coders in Australian healthcare settings, and to compare these to practice guidelines in other countries. |
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| Weight: | 15% |
| Length: | 1000 words |
Assessment task 3: Ensuring the Quality of the Clinical Classification Service – Auditing Coded Data
| Intent: | Intelligence based healthcare requires the information exchanged between healthcare professionals, and across healthcare organisations, is always of a consistently high quality. To ensure confidence in any information produced as part of the clinical coding process, the underlying data must be accurate and fit for purpose. Undertaking regular clinical coding audits forms an essential part of best practice principles in this domain. |
|---|---|
| Weight: | 25% |
| Length: | 2000 words |
Assessment task 4: Coding Exam
| 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. |
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| Weight: | 50% |
| Length: | Maximum 3 hours in duration |
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 92034.
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://pavillion-health.com/codexpert_pricing/
- TurboCoder: https://ecompress.com/buyICD10AMs10th.htm
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
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