Clinical Coder

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Clinical Coder Role Profile

Clinical coding is the process of translating medical information from patient records in hospitals, into alphanumeric codes. A Clinical Coder will spend time reading medical notes / records and analyzing the contents which they then translate into alphanumeric codes that accurately represent the patient’s stay. Clinical Coders locate missing information by whatever process necessary including contacting Medical Secretaries or by pulling case notes and requesting diagnoses from clinical staff where appropriate. They input Clinical Codes onto the Patient Administration Systems, action outstanding clinical coding reports as required as well as dealing with any queries or taking messages for the staff within the Clinical Coding Department.
Typical Job Roles
 Senior Clinical Coder, Clinical Coding Team Leader, Clinical Coding Supervisor, Clinical Coding Trainer, Clinical Coding Auditor, Clinical Coding Assistant Manager, Clinical Coding Manager.
How much will I earn during my Clinical Coder Apprenticeship?
The amount that an employer will pay varies from employer to employer. There is a minimum wage rate for apprentices is £3.90 per hour (April 2019). However, we have many employers who will pay more than this, sometimes there be increments through the year, some roles have bonuses attached.
The thing to remember about your earnings is that this is an apprenticeship and employers are taking a risk with someone who is inexperienced. However, if you are confident in your ability then after your apprenticeship completes you will have over 1 year of experience, a professional CV and qualifications. Remember, it is your apprenticeship and completed properly, it will open doors to your future It career.
How much does the Clinical Coder apprenticeship cost?
As an apprentice, you will NOT pay anything towards your apprenticeship. For employers, you will either receive 100% or 5% funding depending on your size and if you are a Levy paying employer, then you can utilize your Apprenticeship Levy funds.
Entry Requirements
Individual employers will set selection criteria. This might include Level 2 in English Language, Mathematics and a Science subject (preferable Science / Biology).
Qualification Requirements
Apprentices without level 2 English and Maths will need to achieve this level prior to completing the end-point assessment. For those with an education, health and care plan or a legacy statement the apprenticeships English and maths minimum requirement is Entry Level 3 and British Sign Language qualification are an alternative to English qualifications for whom this is their primary language.
Clinical Coder Competencies you will learn
Specific Clinical coding skills:
  • Foundation knowledge of human anatomy, physiology and medical terminology
  • How to deconstruct and understand a medical term
  • An awareness of the role NHS digital and mandatory data set
  • How to apply codes to given diagnosis and treatments
  • The rules and conventions of the latest edition of international statistical classification of diseases and related health problems (ICD-10)
  • Relevant national standards and how to apply them
  • The need for accurate and high quality coded data to support healthcare planning, reimbursement, management of services, statistical analysis and research relevant to Clinical Coding
  • How to navigate through a medical record (paper-based and/or electronic)
  • The basics of Systemized Nomenclature of Medicine – Clinical Terms (SNOMED CT) its uses and benefits, how it complements the classifications and interacts with them
  • The purpose and function NHS Digital Delen specialist, collaborative and information sharing forum
  • Rules and requirements of Information Governance and how these impact on the work of the Clinical Coder

Communication and Information Governance:

  • Different communication methods and how to adapt your communication to suit different audiences including senior clinicians for clarification when necessary
  • Data Protection and Security – The General Data Protection Regulation (GDPR) May 2018 and how it relates to your Clinical Coding role
  • The importance of maintaining confidentiality
  • The importance of information governance and the information governance toolkit

Evaluation and Extraction of data:

  • The impact of coding related data
  • The use of coding related statistics e.g. planning, identifying trends, analyzing clinical outcomes
  • How data produced flows through and out of the organisation and the need to meet local and national deadlines
  • How coded data is used to satisfy many different purposes including Secondary Uses Service (SUS), Hospital Episode Statistics (HES), Hospital Mortality Indicators

IT:

  • How IT systems work and link to other systems within the organisation
  • How to access various systems within an organisation
  • How to navigate and use the NHS Digital Delen website
  • How to identify appropriate and reliable sources of information
  • How to use Display Screen Equipment safely

Work within your organization:

  • The healthcare environment and the different departments you are likely to work with
  • The purpose of the Clinical Coder’s role within the organisation
  • Where Clinical Coding sits in the wider environment
  • What it is like to work in a Clinical Coding office environment
  • Organisational policies and procedures; including the departments Standard Operating Procedure
At Completion of your Data Technician Apprenticeship, you will be able to:

Specific Clinical Coding Skills:

  • Assimilate and retain specialist information
  • Extract information for coding from a variety of sources both paper based and electronic
  • Consistently apply correct coding to a range of typical case notes and more complex scenarios
  • Follow the rules, conventions and standards for clinical coding as defined by NHS Digital Clinical Classifications Service and the World Health Organisation (WHO)
  • Consistently and correctly apply the four-step coding process as set on the NHS Digital website when assigning codes for diagnoses and procedures
  • Apply detailed knowledge of medical terminology, anatomical and physiological terms to translate the patients records into the correct codes
  • Follow locally defined coding rules where they have been agreed by the hospital, documented in the Clinical Coding Policy document and do not contravene the national rules defined by NHS Digital Terminology and Classifications Delivery Service module
  •  Work with clinical teams and administrative staff to ensure that clinical codes are entered onto the correct Finished Consultant Episode (FCE)

Communication and Information Governance:

  • Communicate effectively at all levels with a wide range of individuals, including clinicians, other hospital staff and colleagues
  • Relate appropriately with external agencies
  • Communicate complex clinical coding rules to relevant individuals
  • Ensure strict confidentiality when handling patient notes and information
  • Be involved in departmental internal audits
  • Ensure legal and information governance requirements

Extraction and evaluation of data:

  • Extract information from all types of clinical documentation and assess relevant health record content
  • Correctly interpret data
  • Ensure every data entry is made in an accurate and timely manner against the correct patient’s record
  • Interrogate information and ask appropriate questions to resolve queries
  • Use the internet and systems to research background information regarding diagnostic and procedural statements and seeking advice from senior team members as necessary
  • Identify data quality issues and take appropriate action

IT:

  • Use different IT systems and applications for example: Patient Information Systems, Medicode, Excel, email and internet
  • Enter information accurately and correctly into information management systems

Work within your organisation:

  • Work effectively with other departments within the organisation such as doctors, nurses, ward clerks, informatics
  • Follow organisational policies and procedures
  • Undertake organisational mandatory training as required
Underpinning Skills, Attitudes and Behaviors
  • Agile & Flexible – being tenacious and driven to see projects through to completion. A proven self-starter and have an adaptable approach to meet changing work priorities.
  • Professionalism & emotional intelligence – a high level of professionalism, reliable and dependable, collaborative approach and show empathy and being mindful of others
  • Has a desire to learn and a thirst for knowledge and a willingness to learn from mistakes
  • Shows emotional maturity – Ability to deal with direct exposure to disturbing photographs and case notes, potentially regarding abuse and terminally ill patients. There may be instances where you may be needed to attend a hospital ward where you may witness disturbing scenes
  • Adaptive to environment, working in both an office and busy healthcare environment
English and Maths

Overall, Level 2 English and Maths will need to be passed, if not already, prior to taking the end point assessment.