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Teaching Doctors and Nurses to code accurately

Teaching Doctors and Nurses to code accurately. Linda Best 11.45 -12.30 Wednesday, 7 th December 2011. Good clinical coder. Knowledge of: Medical terminology Medical science Disease processes Investigations, treatments and interventions Content and structure of clinical record

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Teaching Doctors and Nurses to code accurately

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  1. Teaching Doctors and Nurses to code accurately Linda Best 11.45 -12.30 Wednesday, 7th December 2011

  2. Good clinical coder • Knowledge of: • Medical terminology • Medical science • Disease processes • Investigations, treatments and interventions • Content and structure of clinical record • Understanding of classification system • Understanding of coding rules and standards

  3. CLINICIANS/CODERS Clinicians can be clinicians or coders Advantages: Medical knowledge Understanding terminology Disadvantage: Tendency to ‘diagnose’

  4. The effect of good clinical documentation on coding quality • Support quality patient care • Reliable for other purposes: • Research • Planning • Quality activities

  5. Australian Coding Standards (ACS) • The ACS provide coders with national guidelines and advice on how to apply and interpret ICD-10-AM/ACHI • As well as specialty standards, the primary ACS are: • ACS 0001 Principal diagnosis • ACS 0002 Additional diagnoses

  6. ACS 0001 – Principal diagnosis • Important to understand meaning and apply consistently • Difficult area for coders and therefore ACS 0001 Principal diagnosis was developed • The principal diagnosis is based on: • good clinical documentation • understanding of the definition • application of the standard • clinical coder knowledge

  7. ACS 0001 Principal diagnosis cont. “The diagnosis established after study to be chiefly responsible for occasioning an episode of admitted patient care, an episode of residential care or an attendance at the health care establishment, as represented by a code.” (Health Data Standards Committee (2008), National Health Data Dictionary, Version 14, AIHW).

  8. ACS 0002 – Additional diagnoses “A condition or complaint either coexisting with the principal diagnosis or arising during the episode of admitted patient care, episode of residential care or attendance at a health care establishment, as represented by a code.” (Health Data Standards Committee (2008), National Health Data Dictionary, Version 14, AIHW). For coding purposes, additional diagnoses should be interpreted as conditions that affect patient management in terms of requiring any of the following: • commencement, alteration or adjustment of therapeutic treatment • diagnostic procedures • increased clinical care and/or monitoring.

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