User:Little pob/Clinical coder

A clinical coder – also known as clinical coding officer, diagnostic coder or medical coder – is a health informatics professional whose main duties are to analyse clinical statements and assign standard codes using a classification system. The data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.

A clinical coder therefore requires a good understanding of medical terminology, clinical documentation, legal aspects of health information, health data standards, classification conventions, and computer- or paper-based data management. This knowledge can be obtained through formal education, as well as on-the-job training.

Competency levels
Clinical coders may have different competency levels depending on the specific tasks and employment setting.

Entry level coder
An entry level coder, also trainee and novice coder, has completed (or nearly completed) an introductory training course in clinical coding, and whose work is typically checked by an experienced coder before being used.

Intermediate level coder
An intermediate level coder, also trained coder, has acquired the skills necessary to code many cases independently. Coders at this level are also able to code cases with incomplete information. They have a good understanding of anatomy and physiology along with disease processes.

To reach this competency level takes 6 to 18 months. Intermediate level coders have their work audited periodically by an Advanced coder.

Advanced level coder
Advanced level and senior coders have obtained the skills to code all cases including the most complex. Advanced coders will have several years of experience, and may be certified. An advanced coder is also able to mentor entry-level coders, and, in some instances, provide training.

Certification
In some countries clinical coders may seek voluntary assessment based accreditation conducted by professional associations or health authorities. Examples include the Clinical Coding Classification in Australia and the National Clinical Coding Qualification (NCCQ) in the UK.

Clinical coding trainer
In the UK, novice training and refresher courses are provided by an HSCIC registered trainer. To be a registered trainer, the coder must have at least 2 years post-NCCQ coding experience and pass the HSCIC's trainer course.

Clinical coding auditor
Within the NHS, for an audit to comply with the Information Governance Toolkit, coding auditors must have undertaken HSCIC's Clinical Coding Auditor Programme (for which the auditor must have the NCCQ), and be currently registered with HSCIC's Clinical Classifications Service as an auditor.

Nosologist
A nosologist understands how the classification is underpinned. Nosologists consult nationally and internationally to resolve issues in the classification and are viewed as experts who can not only code, but design and deliver education, assist in the development of the classification and the rules for using it.

Nosologists are usually expert in more than one classification, including morbidity, mortality and case mix. In some countries the term "nosologist" is used as a catch-all term for all levels.

Professional associations
In many countries, as well as organizations for health information management professionals as a whole, there are professional bodies specific to representing coders.

Australia

 * Clinical Coders' Society of Australia (CCSA)
 * Health Information Management Association of Australia (HIMAA)

Canada

 * Canadian Health Information Management Association (CHIMA)

United Kingdom

 * Institute of Health Records and Information Management (IHRIM)
 * Professional Association of Clinical Coders UK (PACC-UK)

United States

 * American Health Information Management Association (AHIMA)
 * American Academy of Professional Coders (AAPC).