How to become a Clinical Coder

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.

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