About Clinical Coding

Clinical Coding involves grouping aspects of patient information and characteristics into categories based on standard criteria, logic and conventions.

Clinical statements written in a medical history are analysed to assign standard codes as prescribed by the coding rules applicable to the International Classification of Diseases (ICD) and the International Classification of Healthcare Interventions (ICHI) developed and maintained by WHO.  Individual countries may extend this standard classification to meet their needs and this generates individual versions such as:

• ICD-10-AM and ACHI  developed in Australia and used widely around the world.  The Independent Health and Aged Care Pricing Authority (IHACPA), an independent Government Agency, undertakes reviews and updates of existing classifications relative to a number of different health service categories.
• ICD-10-CM and CPT or PCS – developed in the USA and used widely around the world.

These classification systems consists of around 155,000 codes!  The codes cover concepts including:

• diagnosis (including those for traditional medicines in ICD-11)
• causative agents (infectious and parasitic agents as well as causes of injury)
• place where injuries occur
• activities being undertaken when injured
• other reasons for care such as surveillance or preventative healthcare
• interventions, including surgical and non- surgical procedures, education, therapy, administration of therapeutic agents etc.

The record pertaining to healthcare visits can be coded according to this classification system to reflect the reason for care and what was done.  Most countries around the world collect data for all hospital admissions.

For current or past coders wishing to learn more about the latest ICD-10-AM edition or ICD-11 go to https://learn.ihacpa.gov.au/.

These codes form part of routine data collections required for:

• Morbidity Reporting (reporting of disease and injury in the community) – this helps to determine initiatives to improve the health and safety of the community.
• Research
• Clinical audits
• Epidemiological studies
• Measuring treatment effectiveness
• Assessing health trends
• Hospital funding
• Cost analysis
• Resource allocation
• Health Care Planning purposes

The ICD and ICHI codes (or their national variant) and a number of other routinely collected variables including: age, sex, separation mode (whether the patient went home or to another hospital or died), length of stay, same-day status, admission weight for neonates and hours of mechanical ventilation are used to group the number and type of patients treated in admitted acute episodes of care, into a more manageable number of categories.  Each of these categories include patient’s with similar medical conditions and similar treatments (e.g. hip replacement group includes all with a hip replacement which might be done for osteoarthritis or for a fracture.

Each group is clinically meaningful and relates to the resources required by a hospital (the costs of delivering the service). Internationally these are known as Diagnosis Related Groups.  In Australia they are known as Australian Refined Diagnosis Related Groups (AR-DRGs), an Australian admitted patient classification system. They are used to calculate public hospital funding on an activity basis and increasingly are being adopted by insurers to achieve more consistent and efficient funding methodologies

They are also used for:

• Performance management
• Benchmarking
• Bunding agreements between private hospitals and insurers
• Education
• Epidemiology
• Research into the quality of healthcare and patient safety
• Health service planning

Clinical coding is part of a Health Information Professional’s position. Clinical coding positions may be referred to as a Clinical Coder, Clinical Coding Officer, Diagnostic Coder, Medical Coder, Medical Records Coder, or Nosologist.  In some countries this task is undertaken by medical officers, however the increasing requirement for complex standards and rules, particularly associated with the use of these codes for funding has increased the need for these highly specialised skills.

In Australia there is a high demand for these skilled professionals who must have the Diploma of Clinical Classification (or its equivalent) as an entry level requirement.  This professional group is on the list of preferred professions for the purpose of migration to Australia

The World health Organisation (WHO) has authorised the publication of ICD classification systems. In Australia this includes the use of the Australian Classification of Health Interventions (ACHI) and applies the Australian Coding Standards (ACS), known as the Australian Modification (AM).

The US has developed and uses its own Clinical Modification (CM) plus their Procedure Coding System (PCS) for inpatients and CPT for outpatients.

Many countries have adopted earlier editions of this Australian version, others have adopted the US version or created there own extension.

eHealth Education (eHE) is a Registered Training Organisation (RTO) approved by the Australian Skills Quality (ASQA) to deliver the Diploma of Clinical Coding.  We use a simulation cloud based system (eHRol). The Diploma is designed to prepare Australian students for a clinical coding career.  It is offered by several organisations but the qualification is considered to be the same, no matter who delivers it and is recognised by the Professional Body – the Health Information Management Association of Australia.

Other countries don’t necessarily require this comprehensive qualification to meet their coding skill requirements. eHE also provides NON-RTO Clinical Coding courses to meet this international market need.

You can learn more about the options for Australian and International Students by reading on below.