PUB202 Advanced Clinical Classification

Unit Outline: Semester 1 2024, Kelvin Grove, Internal

Overview

It is essential that Health Information Managers understand clinicians' responses to various disease processes, how this information is documented in patient records, how to access data from information feeder systems and how these relate to the process of clinical coding. This unit integrates the knowledge of medical terminology, anatomy and pathophysiology gained from PUB100 and the basic processes of coding gained from PUB101 to build an understanding of the way to interpret documented diagnoses, procedures and interventions. This more advanced understanding will be applied to abstraction of clinical details from hospital documentation and application of knowledge of coding processes and the Australian Coding Standards in a practical setting. The importance of coding quality and techniques for quality assessments will be introduced. The relationship between coding and hospital funding will also be discussed, as will be uses of coded data to report on health issues.

Learning Outcomes

On successful completion of this unit you will be able to:

1. Apply knowledge of major diseases and disorders of the body to clinical documentation to interpret and abstract necessary information about pathology, presentation, diagnoses, complications, diagnostic and therapeutic procedures;
2. Apply the standards and conventions for health classification to assign codes using complex clinical documentation;
3. Evaluate health records to determine completeness and suitability for classification purposes;
4. Apply clinical coding auditing processes to identify factors that impact upon the quality and reliability of coded data.

Content

Learning Approaches

This unit adopts a blended learning approach with lectures and tutorials each week in synchronous face-to-face and online modalities. Lecture sessions will cover core content integral to achievement of the unit's learning outcomes. Tutorials will support the application of acquired coding knowledge and skills and provide opportunities for formative feedback from academic staff. Tutorials will include individual and group workbook exercises aimed at developing advanced skills through coding of deidentified summary records and reports. The student group will be used to apply an inquiry-based approach to problem-solving through discussions about, and coding of, complex clinical documentation. The importance of quality coding for reporting on health issues, for funding and health care management purposes will be discussed. Coding quality principles, tools and techniques will be examined. At the end of the semester, students will be exposed to coding from actual medical records in either a hospital or online setting. In the hospital setting, students will be supported by hospital coders and will code from either paper based or electronic medical records or a combination of both. The online placement involves use of a large database of deidentified scanned medical records sourced from hospitals. The codes will be added to the database and automated feedback and unit coordinator support will be provided. 

The practical placement in this unit requires you to maintain the confidentiality of information that is accessed during the placement (unless required by law), including but not limited to patient/client medical records and any other documents which contain material of a confidential nature or information which relates to the personal affairs of the placement site, patients or staff.

Feedback on Learning and Assessment

Feedback on assessment 1, the exercises completed outside of classroom hours and the coding activities conducted in tutorials will form the basis of formative assessment. This feedback should be used to support completion of summative assessment items 2 and 3. Individual and whole of class feedback on these assessments will be provided. Placement supervisors and the unit coordinator will provide advice and support relating to practical coding experiences during your placement.

Assessment

Overview

The overall result that you will obtain for this unit is Satisfactory or Unsatisfactory. In order to pass the unit (i.e. to be assessed as Satisfactory), there are three pieces of assessment to be completed. Assessment 1 is a mandatory formative assessment item, assessments 2 and 3 are summative assessments. At the end of the semester, you will participate in a work integrated learning experience in a hospital or through use of an online coding platform Each task is designed to assess particular learning outcomes.

Special conditions of assessment
This unit includes special conditions of assessment. In order to pass the unit, you must demonstrate:

1. completion of Assessment 1, the formative coding scenario item. This assessment is designed to identify individual coding problems and misunderstandings to allow these issues to be reviewed before moving on to more advanced coding concepts;
2. successful completion of assessment item 2 designed to demonstrate understanding of coding quality issues;
3. successful completion of assessment item 3 at a pass level or higher. Note that this assessment item has an 80% pass mark, which reflects the health industry requirement for high quality coding. Successful completion of assessment item 3 is required in order to be permitted to undertake the coding placement.

4. completion of the required hospital or online Work Integrated Learning placement, demonstrated through submission of a completed activity sheet, signed by the placement supervisor to specify that the placement hours have been satisfactorily undertaken.

Threshold assessment conditions

1. In this unit, threshold assessment conditions apply. If you do not achieve the 80% pass mark for assessment item 3, you are able to make one resubmission of this task for the minimum pass level, but only when your initial achieved mark is within 10% of the minimum pass level of 80% i.e. your initial mark needs to be between 72.0% and 79.9% in order for you to be eligible for a second attempt. If your initial mark is less than 72.0%, a second attempt is not possible.

Unit Grading Scheme

S (Satisfactory) / U (Unsatisfactory)

Assessment Tasks

Assessment: Coding Scenarios Formative

You will apply your knowledge of the structure, organisation and conventions of ICD-10-AM and ACHI to documented clinical information using the Australian Coding Standards. This formative item is designed to allow you to review your understanding of classification techniques and evaluate your understanding of the materials covered in PUB101 and the first weeks of PUB202. Feedback provided will allow you to identify areas where you need to focus your attention in order to support your readiness for Assessment items 2 and 3. Although it does not count towards your final grade, your progress in the unit is conditional on you completing this assessment item.

This assignment is eligible for the 48-hour late submission period and assignment extensions.

Assessment: Coding Quality Assessment

This assessment requires development of a coding quality report. Knowledge of the ICD-10-AM, ACHI and the Australian Coding Standards and the various quality assessment techniques discussed in classes will be used to propose a methodology for an assessment of a specified coding issue. Recommendations to address quality issues identified will be made.

This assignment is eligible for the 48-hour late submission period and assignment extensions.

Assessment: Coding Scenarios Summative

You will apply your knowledge of the structure, organisation and conventions of ICD-10-AM and ACHI to abstract details and assign codes to documented clinical information using the Australian Coding Standards. This assessment has a pass mark of 80%, set to reflect industry standards. As accurate coding is an important pre-requisite for ensuring hospital funding is appropriately allocated, the 80% pass mark reflects the importance of high quality coding for the health industry. Note that students who do not reach the required 80% at their first attempt but whose mark is within 10% of the threshold will be granted a second attempt to demonstrate their competency.

This assignment is eligible for the 48-hour late submission period and assignment extensions.

Threshold Assessment:

For assessment 3, threshold assessment conditions apply. If a student does not achieve the 80% pass level for this assessment item, one second attempt resubmission of this task may be made. To be eligible for the second attempt, the initial mark must be within 10% of the minimum pass level of 80% ie the initial mark needs to be between 72.0% and 79.9% in order to be eligible for a second attempt. If the initial mark is less than 72.0%, a second attempt is not possible.

Academic Integrity

Students are expected to engage in learning and assessment at QUT with honesty, transparency and fairness. Maintaining academic integrity means upholding these principles and demonstrating valuable professional capabilities based on ethical foundations.

Failure to maintain academic integrity can take many forms. It includes cheating in examinations, plagiarism, self-plagiarism, collusion, and submitting an assessment item completed by another person (e.g. contract cheating). It can also include providing your assessment to another entity, such as to a person or website.

You are encouraged to make use of QUT’s learning support services, resources and tools to assure the academic integrity of your assessment. This includes the use of text matching software that may be available to assist with self-assessing your academic integrity as part of the assessment submission process.

Further details of QUT’s approach to academic integrity are outlined in the Academic integrity policy and the Student Code of Conduct. Breaching QUT’s Academic integrity policy is regarded as student misconduct and can lead to the imposition of penalties ranging from a grade reduction to exclusion from QUT.

Requirements to Study

Requirements

COVID-19, Hepatitis B, Measles, Mumps, Rubella, Varicella, and Pertussis vaccinations

Blue card, police check

Mandatory placement site documentation

HIM Placement T-shirt

Blue Card

A blue card is required to complete this unit. A blue card confirms that you have passed a screening of your criminal history (the Working with Children Check) and have been approved to work with children and young people. For more information on the blue card and how to apply please visit the QUT website.

Costs

For students whose placement sites are outside of Brisbane, there may be travel and/or accommodation costs associated with the work integrated learning placement.

Resources

Resource Materials

Prescribed text(s)

HIMAA. (2021). The Australian dictionary of clinical abbreviations, acronyms & symbols. (8th Edition). Sydney: HIMAA. Available at https://www.himaa.org.au/our-work/publications/dictionary/ as a hard copy book or online version

This text will also be used in PUB370 in future years.

Independent Hospital and Aged Care Pricing Authority (2022). The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM/ACHI/ACS) (12th ed.). Sydney: Independent Hospital and Aged Care Pricing Authority.

Independent Hospital and Aged Care Pricing Authority. (2022). The Australian Classification of Health Interventions (12th ed.). Sydney: Independent Hospital and Aged Care Pricing Authority.

Independent Hospital and Aged Care Pricing Authority. (2022). The Australian Coding Standards (12th ed.). Sydney: Independent Hospital and Aged Care Pricing Authority.

You will need to obtain one of the available versions of the classifications - either hard copy books or an eBook version. Details about these will be provided prior to the commencement of the semester. 

Note that these required references are the same as those used for PUB101. Students do not need to obtain them again if they have studied that unit in the semester immediately prior to studying PUB202 although  an extension to your original license may be required if using an eBook version of the classifications. 

Note that the eBooks are designed for use with Windows computers but students with a non-Windows computer can use a Windows based application for a Mac, Parallels desktop, to load and use the software. 

Recommended text(s)

Highly Recommended Reference:
Harris, P., Nagy, S., & Vardaxis N. (Eds.). (2018). Mosby's Dictionary of Medicine, Nursing & Health Professions. (Revised 3rd Australian and New Zealand Edition). Chatswood, NSW: Elsevier, Australia. ISBN: eBook 978-0-7295-8691-7, Hardcover 978-0-7295-2480-7. 

Risk Assessment Statement

As this unit involves Work Integrated Learning in a health facility, students should be aware of, and abide by, the privacy and confidentiality and health and safety requirements of the workplace. Students are expected to undergo any induction or other training provided in the workplace for employees or visitors as appropriate. In addition, substantial computer-based work will be required. You should refer to the safe computer use information detailed on the Student Services website.

Disclaimer: Offer of some units is subject to viability, and information in these Unit Outlines is subject to change prior to commencement of semester.

Course Learning Outcomes

PU51 Bachelor of Health Information Management

1. Critically evaluate and apply theoretical and technical perspectives on health information management (HIM), applicable to professional practice to solve routine and emergent problems. [Knowledge, Practice]
   Relates to: Coding Scenarios Formative, Coding Quality Assessment, Coding Scenarios Summative
2. Initiate effective approaches for engaging in critical thinking, decision making and problem solving that reflect diverse perspectives and culturally safe and responsive practice, encompassing evidence-based HIM solutions. [Practice, Values/Disposition
   Relates to: Coding Scenarios Formative, Coding Quality Assessment, Coding Scenarios Summative
3. Employ digital capabilities in accessing, evaluating, utilising and communicating digital health information across a range of stakeholders, and intra- and inter-professional contexts that demonstrate independence, accountability, creativity and initiative as a HIM professional. [Practice, Values/Disposition]
   Relates to: Coding Scenarios Formative, Coding Scenarios Summative
4. Exercise judgement in the context of HIM, informed by sustainable, legal, ethical, and professional perspectives that promote social inclusivity, multidisciplinary collaboration and reflective practice. [Values/Disposition, Knowledge, Practice]
   Relates to: Coding Scenarios Formative, Coding Quality Assessment, Coding Scenarios Summative