How to become a Clinical Coder

Clinical coders translate descriptions of medical diagnoses and procedures into codes, which record healthcare data.

Personal requirements of a Clinical Coder

  • able to perform precise and detailed work
  • able to concentrate for long periods of time
  • excellent problem-solving skills
  • good communication and interpersonal skills
  • able to work as part of a team
  • interested in healthcare procedures
  • willing to continually update skills and knowledge.

Duties & Tasks of a Clinical Coder

Clinical coders may perform the following tasks:

  • read and analyse medical records to help identify all diagnoses, operations and procedures relevant to the current period of patient care
  • clarify inconsistent or non-specific information in a medical record by consulting with the responsible medical practitioner
  • allocate codes to patients' current period of care, using knowledge of the information contained within the International Classification of Diseases, 10th Revision Australian Modification, commonly referred to as ICD-10-AM
  • conduct assessment of work to ensure there is continuous improvement in ICD-10-AM coding and collection of quality health data
  • assess the medical record content and highlight shortcomings to management
  • maintain ICD-10-AM coding books to make sure they are updated to the current version being used
  • assist with the education of clinical staff with regard to ICD-10-AM
  • work with computing and finance staff
  • ensure the patient episode is allocated to the correct Diagnosis Related Group (DRG)
  • assist with medical research and casemix (patient statistics) projects.

Working conditions for a Clinical Coder

Clinical coders work closely with medical staff who are responsible for recording the information required for coding medical data within patients' medical records.

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