Experienced Clinical Coder

To accurately extract and evaluate all relevant information concerning a patients episode of care involving identifying and interpreting often very complex clinical data detailing principal diagnosis and procedures, and any co-morbidities/complications and co- existing systemic conditions. This information is located in paper clinical record and various electronic systems. To translate this information into codes using ICD10 (International Classification of Diseases vol 10) and OPCS 4 (Office of Population Censuses and Surveys vol 4.8 which is then processed to create HRGS (Health Resource Groups) this is used to determine under the National tariff scheme the amount of funding the trust receives from the PCTS. Apply the rules and conventions of ICD10 and OPCS4 and take responsibility for updating training manuals and publications when changes or clarifications issued by the NHSIA. Inform the Coding supervisors of any national and/or local coding changes in order that they may be
documented in manuals and the Coding Policy and Procedures To ensure all coded information extracted from provider spells/casenotes is accurate and reflects the full extent off all diagnosis and procedures that are provided by the clinician for every patient episode within an agreed time from patient discharge which supports the requirements of commissioning. Regular use of clinical coding reminder lists, and information systems are to be used to assist this process. Maintain level of accuracy within the complex specialties at PHU required for experienced Clinical coder by attending specialist workshops, refresher training and working to HSCIC standards. To maintain a comprehensive knowledge of anatomy and physiology, medical procedures, diagnosis, and terminology as applied across specialties. Establish a liaison with clinicians and specialty administration staff to ensure clinically relevant information is available to support the highest quality clinical coding, including the
communication of complex clinical coding rules to relevant parties. To liaise with health records staff on all clerical aspects of casenote requests and tracking and the tracing of lost casenotes. Managing own workload to maintain departmental standards of productivity and quality, ensure high quality clinical coding of complex clinical records from a wide variety of sources, and in all Trust specialties, to ensure an accurate and timely coded record of Trust clinical activity. Communicate complex coding rules to medical, clinical, administrative staff and external agencies to maximise recording of relevant clinical history and events, in order to accurately portray the clinical workload of the Trust and morbidity of admitted patients. Advise less experienced coders in the correct coding of clinical notes as required. To regularly review, and if necessary, revise work practices and information flows in conjunction with the Coding Manager, considering the needs of the
Directorates, Trust, and NHS mandatory requirements. Any changes in local coding policies should be ratified by the clinician and be included in the Clinical Coding Policy and Procedures document. To be aware of the weekly list of incomplete episodes and liaise with the Coding clerk to ensure these are retrieved and coded. On completion of episodes use the Patient Administration System to identify any other incomplete episodes and to take the appropriate action to deal with them. The return of notes for completion of provider spells is to be in accordance with departmental procedures. Use the Medical Encoder for accessing clinical information for coding purposes and for passing completed coding details to the PAS system. Use the minestrone and Maternity System (badgernet) for accessing clinical information to clarify diagnosis for coding purposes. To ensure that the PAS system is updated with the correct information on location and destination of all received
casenotes to ensure they are available if required using Casenote Tracking. To take responsibility for passing any coding queries via the Coding manager to the NHS centre for classification. Participate in pilot studies and special projects as required, be aware of new procedures introduced to the Trust for the purposes of clinical coding and assist in the accreditation and audit of data both internally and externally as required by the Trust policy of Clinical Governance. Participate in Individual Performance Review (IPR) and undertake identified training and development as agreed with the Coding Manager, including attending training courses, workshops, and conferences both internally and external as required. As part of the Trust Clinical Coding Team, provide cover for colleagues in times of annual leave or sickness absence to ensure continuity of work and also participate in induction and training of new team members. Carry out any other task consistent with
grade and experience as determined by the Coding Manager, or other Senior Manager within the Corporate Division. Ensure effective team working with other members of the clinical directorates ensuring skills and knowledge are transferred as appropriate, whilst ensuring working procedures are properly documented and maintained. Take responsibility for ensuring patient information that you handle is always kept confidential, within a secure environment, and only referenced for the purpose of conducting your duties.