What is Clinical Coding?

Clinical coding is the translation of clinical terminology as written by a clinician into statistical code. The term "clinical coder" is somewhat a misnomer as the actual role is that of a translator of clinical terminology as opposed to a clinical practitioner.

e.g. a clinician records a diagnosis for a patient as "calculus (or stone) in the urinary bladder. The clinical coder will translate that terminology into the ICD-10 (International Classification of Diseases V10) code N21.0 Calculus in bladder.. (The process is much more complex than this example implies.)

The schemes used are the ICD-10 (International Classification of Diseases V10), published by the World Health Organisation and the procedure/interventions coding scheme OPCS 4 (Office of Populations Census and Surveys V4) published by the Stationary Office and produced by NHS Connecting for Health.

What are the codes used for?

The clinically coded data is used to support a variety of requirements in the NHS:

• Epidemiology
• Generation of payment
• Resource management
• Casemix analysis
• Audit
• Information and Clinical governance

Training to be a Clinical Coder in the UK

In the UK, clinical coding training is usually delivered once a coder is in post. Training may be delivered through in-house training and support by hospitals who employ trained clinical coding trainers, through external NHS training courses such as those run by the department of health agency - Connecting for Health or through commercial suppliers of clinical coding services (such as those who sponsor this Association - see our home page). A coder who has no previous experience of clinical coding should expect a to complete a foundation/basic training course that covers the fundamental rules and should give them the necessary basic skills to code. The Association recommends that as a minimum training is refreshed or further supported on an annual basis through attendance at workshops or refresher trainings. Either way training needs should regularly be assessed and support provided as required. It is important to remember that the coded data forms part of patients record and therefore must be accurate and complete.

The Clinical Coding Profession

There are three key elements that comprise clinical coding professionalism: Competence; Integrity, Responsibility and Accountability; and Public Duty.

Competence:

A professional clinical coder should be able to demonstrate that their skills and knowledge are current and they have the capability to perform the task of clinical coding. They should have practical experience to back their theoretical knowledge and also have a range of soft skills including communication, inter-personal skills and for some, the ability to be able to manage and/or lead others. These competences have to be underpinned by a firm ground of experience, knowledge and understanding , backed by appropriate qualifications and continuing professional development (CPD).

Integrity, Responsibility and Accountability:

A professional clinical coder must demonstrate a commitment to a published code of conduct or ethical standard. In parallel to this is the recognition that professionals have a set of obligations and responsibilities to the profession which sit alongside their employer contract of employment.

Public Duty:

A professional is also required to work in the best interest of society and to use their skills, attributes and experience to translate clinical terminology with diligence for the public good. This requirement, in combination with that of personal accountability, places a heavy responsibility on the professional clinical coder. The coder is not only responsible for making balanced and thoughtful decisions, but is required to understand and be willing to explain the ramifications, consequences and the impact to others, of those decisions.