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