Reading medical notes / records and analysing the contents which then translate into alphanumeric codes that accurately represent the patient’s stay.
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.
Summary of Standard
https://www.instituteforapprenticeships.org/apprenticeship-standards/clinical-coder/
Full Standard
