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|SOUTH AFRICAN QUALIFICATIONS AUTHORITY|
|Higher Certificate: Diagnostic and Procedural Coding|
|SAQA QUAL ID||QUALIFICATION TITLE|
|66389||Higher Certificate: Diagnostic and Procedural Coding|
|Task Team - Diagnostic and Procedural Coding|
|PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY||NQF SUB-FRAMEWORK|
|HW SETA - Health and Welfare Sector Education and Training Authority||OQSF - Occupational Qualifications Sub-framework|
|National Higher Certificate||Field 09 - Health Sciences and Social Services||Promotive Health and Developmental Services|
|ABET BAND||MINIMUM CREDITS||PRE-2009 NQF LEVEL||NQF LEVEL||QUAL CLASS|
|Undefined||120||Level 5||NQF Level 05||Regular-Unit Stds Based|
|REGISTRATION STATUS||SAQA DECISION NUMBER||REGISTRATION START DATE||REGISTRATION END DATE|
|LAST DATE FOR ENROLMENT||LAST DATE FOR ACHIEVEMENT|
|In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.|
This qualification does not replace any other qualification and is not replaced by any other qualification.
|PURPOSE AND RATIONALE OF THE QUALIFICATION|
This entry-level qualification provides learners access to Clinical Coding that is integral to the healthcare industry, in both the public and private sectors. Qualifying learners will be able to be employed in specific occupations that involve Clinical Coding, data collection, supervising data collection, data editing/auditing, data capturing, elementary analysis of data and research.
The purpose of this qualification is to provide learners with a well defined knowledge of diagnostic and procedural coding to enable the learner to practically apply professional skills in the chosen field. Learners will systematically access, critically analyse and evaluate existing knowledge in the field of clinical coding. This qualification enables learners to apply knowledge, skills, attitudes and values to create effective intervention strategies in clinical coding.
Qualifying learners will be able to:
Diagnostic coding and procedural coding lend themselves well to the improvement of healthcare efficiency. Accurate and standardised recording of diagnoses and procedures enables, analysis of information for patient care, research, performance improvement, healthcare planning and facility management. It also enables fair reimbursement for healthcare services rendered and communicates data in a predictable, consistent and reproducible manner. Diagnostic and Procedural Coding is mandatory for all healthcare professionals. Over and above the basic generic knowledge and skills that form the foundation for all workers within the healthcare environment, each field of practice has its own specific advanced body of knowledge, skills and competencies, where the use of Diagnostic and Procedural codes are mandatory.
Since ICD-10 is the national diagnostic standard in South Africa, it is essential to provide all workers in the South African healthcare environment with the opportunity for ICD coding knowledge and skills. The clinical coding qualification has a practice focus and also promotes healthcare workers to ably code accurately, identify gaps in work practice, think independently and creatively and propose interventions within the chosen focus area. This qualification is also designed to enable candidates to pursue further personal and professional development and to promote life-long learning.
There is a critical skills shortage of qualified/accredited clinical coders especially at this time when clinical coding is increasingly becoming critical for business to all organisations in the South African healthcare environment. This entry-level qualification provides learners access to clinical coding that is integral to the healthcare industry, in both the public and private sector. Qualifying learners will be able to be employed in specific occupations that involve Clinical Coding, data collection, supervising data collection, data editing/auditing, data capturing, elementary analysis of data and research. The Healthcare Industry and Organisation/Structures that utilise Diagnostic (ICD) and Procedure Codes have projected an increase in the need for qualified individuals that are able to competently code and manage information of which clinical coding is a critical component. This qualification helps to contribute to a quality hierarchy of skills required to provide quality health data in the healthcare industry.
This Qualification contributes to the holistic development of the learner by providing a learning pathway and further development opportunities within clinical coding and related fields. The competencies gained through completion of this Qualification also add value to economic development in an information-driven society where monitoring and evaluation are critical components.
|LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING|
|It is assumed that learners are already competent in the following:
Recognition of Prior Learning:
Pre-assessments in both the Fundamental and Core areas of learning associated with this qualification will be conducted on learners prior to entry into the qualification. Successful demonstration of competence against all criteria contained in individual unit standards, against which prior learning is measured, will culminate in the award of relevant credits to the learner. Learners will not be required to repeat learning in those areas where prior learning is recognised and accredited.
The Recognition of Prior Learning process will also be applied where learners who have achieved this Qualification wish to continue in further learning.
Access to the Qualification:
National Senior Certificate or Further Education and Training Certificate at NQF Level 4.
|RECOGNISE PREVIOUS LEARNING?|
The Fundamental Component consists of unit standards to the value of a total of 30 credits, all of which are compulsory.
The Core Component consists of unit standards to the value of a total of 60 credits, all of which are compulsory.
The Elective Component consists of a minimum of 30 credits, which credits are required to complete the qualification. These credits may be obtained from a combination of unit standards to be chosen by the learners - in agreement with the provider - from various disciplines and/or contexts such as health information management, insurance health economics, or any other relevant field of learning.
It is envisaged that specialisations such as clinical auditing, health information management, and procedure coding could be accommodated in this qualification in the future.
|EXIT LEVEL OUTCOMES|
|1. Explain the rules, conventions and guidelines of the ICD Procedure Coding and the South African Coding Standards
2. Assess health records to extract diagnoses and recorded procedures and accurately assign ICD and Procedure Codes.
3. Explain the legal and ethical requirements and implications associated with assigning Diagnostic and Procedure Codes to health information systems.
Critical Cross-Field Outcomes:
This qualification promotes, in particular, the following critical cross-field outcomes:
|ASSOCIATED ASSESSMENT CRITERIA|
|Associated Assessment Criteria for Exit Level Outcome 1:
> Range: Clinical information includes and is not limited to health records, medical reports, and medical terminology.
> Range of conventions include but are not limited to Combination Coding, external cause codes, sequelae codes, coding of local infections, dagger and asterisk codes.
Associated Assessment Criteria for Exit Level Outcome 2:
> Range: Different classifications include but are not limited to: Open, Closed, Statistical, Procedural, Diagnostic, Nomenclature, Family of classification.
Associated Assessment Criteria for Exit Level Outcome 3:
Note: Clinical Coding implies ICD and Procedure Codes.
> Range: The healthcare industry includes but is not limited to: medical benefit schemes, health insurance, Road Accident Fund, Compensation for Injuries and Diseases in the workplace, information technology, Department of Health, Council for Medical Schemes.
The Qualification will be awarded to learners who are able to successfully demonstrate competence, in a practical context, against all the specific outcomes contained in all unit standards and their associated assessment criteria, embedded knowledge (theory) and critical cross-field outcomes (generic abilities).
Integrated assessment practices are achieved through the design and development of assessment activities that make use of a variety of assessment methods and tools that measure not only the learner's knowledge and ability to perform practical tasks and activities within a familiar context, but also challenges learners to demonstrate their ability to deal with problems and/or difficult situations that might or can arise in the workplace. Learners are required to demonstrate their ability to adapt their performances to meet the requirements of changed circumstances and to reflect on the what and the why of their actions.
Summative assessment consists of knowledge tests combined with assignments, case studies and practical demonstrations.
The assessment methods and instruments used to assess learners in the context of this Qualification can be applied to the assessment process for Recognition of Prior Learning. A holistic approach is applied when RPL assessments are conducted and include methods and tools that allow for evidence to be gathered from sources located within the broader context where the learner's knowledge and skills have been acquired over a period of time. These assessment methods and tools include assessments of the learner conducted by peers or superiors, certificates of attendance for short courses or panel assessments.
|This qualification compares favourably to similar qualifications/courses in the international arena. This has been verified through the World Health Organisation (WHO) Morbidity work group. The WHO-Family of International Classifications (FIC) Education Committee in a Joint Collaboration with the Education Committee recently formulated the "Morbidity requirements for ICD Education and Training" and this is actually the Core Curriculum and the Learning Objectives for the current ICD-10 Morbidity Coders which, by and large, measures up to the requirements contained in the global document. Similar courses are facilitated in some countries, such as the United Kingdom(UK), the United States of America(USA), Australia and Canada. The following training courses for clinical coders were selected from among these countries as representing best practice.
The following courses are offered in Australia: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD - 10-AM), Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS).
These courses are designed for learners without any prior knowledge of clinical coding. There is an emphasis on developing skills in extracting information from medical records. These courses are structured to assist learners to progress through the concepts of coding, to follow the correct coding pathways and to apply the Australian Coding Standards. On completion of any of these courses, learners should be able to:
At the completion of the HIMAA (Health Information Management Association of Australia) Introductory ICD-AM, ACHI and ACS clinical coding course a learner will have the concepts and skills to be employed as a clinical coder. However, further on-the-job training is required. Some learners choose to continue on to the HIMAA Intermediate ICD-AM, ACHI and ACS clinical coding course to gain a higher level of skill.
Intermediate ICD-AM, ACHI and ACS clinical coding course prerequisites:
Learners are first required to sit the HIMAA Challenge Examination for Intermediate ICD-AM, ACHI and ACS Clinical Coding.
This course will be of value to those coders who have already completed an Introductory ICD-AM, ACHI and ACS clinical coding course and want to learn more. It will also be valuable for those coders who want to refresh their skills because they have been out of the coder workforce recently, or because they have not had the opportunity to code a varied casemix in their current position. It is recommended that potential learners have coding experience gained in a medical record department.
At the completion of the HIMAA Intermediate ICD-AM, ACHI and ACS clinical coding course learners should be able to:
1. Analyse moderately complex medical records from a range of specialities to produce coded clinical data;
2. Use appropriate resources to assist with moderately complete clinical coding requirements; and
3. Identify sequencing requirements in moderately complex medical records
Learners should also have greater knowledge and skills in identifying and applying ICD-AM, ACH and ACS edition changes.
Advanced ICD-AM, ACHI and ACS 6th Edition Clinical Coding Course
All potential learners must meet the prerequisite of a pass mark of 80% in the pretest to be eligible to enrol. The course will be of value to coders who already have significant experience in clinical coding and who wish to gain exposure to a broad casemix at an advanced level.
The course will further educate experienced clinical coders to better understand coding conventions, standards and practices in an extensive casemix and will develop the skills and knowledge required to code highly complex medical records.
The course contains 20 modules with each module containing text, references and self-assessment exercises and six assignments distributed throughout the 20 modules. A grade average of 80% for the 6 assignments is required to pass the HIMAA Advanced ICD-AM clinical coding course. A Certificate of Achievement will be issued on completion of the Programme. A pass in the HIMAA Advanced ICD-AM, ACHI and ACS clinical coding course meets the requirements to pass the Part 1 assessment for Clinical Coder Certification.
United Kingdom (UK):
The National Health Service (NHS) Clinical Coding Foundation course is offered in the UK. An 18 day course of classroom training provides optimal learning conditions for the delegate. The course is divided into four modules delivered over a three month period to provide formal training in the use of the classifications ICD and Office of Population, Census, Surveys, Fourth Revision (OPCS-4) used in the NHS. The course aims to provide the novice coder with a thorough grounding in the theory of classifications as well as opportunities to develop practical skills in clinical coding. This course is aimed at novice coders who are already working within the clinical coding fraternity. Ideally, delegates will be working in the NHS and will have been recently recruited into the clinical coding profession. They possess little knowledge on the subject and have not previously attended a basic clinical coding training course.
At the end of this course delegates will be able to:
United States of America(USA):
In the USA, certification is a means for showing that a credentialed professional possesses the knowledge and skills necessary for the optimal performance of his or her job. Through credentialing, the practitioner's employer, peers, and the public are reassured that he or she is both competent and well-informed in the daily and accurate administration of his or her professional duties. Certain professions (for example doctors, lawyers, technicians, and others) require that individuals be certified, owing to legal or safety reasons or high professional standards. Whatever the reason, credentialing makes a professional a trustworthy and more likely candidate for gainful employment and career advancement.
Other benefits include:
Types of certification:
The RHIA is an expert in managing patient health information and medical records, administering computer information systems, collecting and analyzing patient data, and using classification systems and medical terminologies. RHIAs possess comprehensive knowledge of medical, administrative, ethical and legal requirements and standards related to healthcare delivery and the privacy of protected patient information.
Professionals holding the RHIT credential are health information technicians who ensure the quality of medical records by verifying their completeness, accuracy, and proper entry into computer systems. RHITs use computer applications to assemble and analyze patient data for the purpose of improving patient care or controlling costs. RHITs often specialize in coding diagnoses and procedures in patient records for reimbursement and research.
The CCA is an entry-level credential that validates competence of coding fundamentals in new graduates and those new to the profession.
Highlights the advanced coding and analysis skills of experienced coders in hospital settings. Assesses mastery or proficiency in coding rather than entry-level skills
The CCS-P credential underscores the advanced coding and analysis skills of experienced coders. CCS-Ps work in physician-based offices or clinics, group practices, multi-specialty clinics, or specialty centers.
The only combined privacy and security credential available in the healthcare industry. The Certified in Healthcare Privacy and Security (CHPS) credential denotes competence in designing, implementing, and administering comprehensive privacy and security protection programmes in all types of healthcare organisations. Expands professional opportunities for attorneys, privacy officers, IT professionals, and healthcare professionals
CHDAs demonstrate expertise in health data analysis and the knowledge to acquire, manage, analyze, interpret, and transform data into accurate, consistent, and timely information, while balancing the "big picture" strategic vision with day-to-day details. CHDA-certified professionals also exhibit broad organizational knowledge and the ability to communicate with individuals and groups at multiple levels, both internal and external.
National Coding for Healths Systems (NCHDS) - core curriculum excerpts:
Healthcare Delivery Systems
Intent: To provide an awareness of the organization, financing and delivery of healthcare services
International Classification of Diseases (ICD)
Intent: To develop an understanding of the ICD and to develop the knowledge and skills that is necessary to assign valid diagnostic codes.
How to code
Intent: To provide detailed instruction and experience on how to apply the coding rules
and assign codes.
Intent: To raise awareness about the various factors that influence the quality of coded
data and describe techniques for assuring the highest quality data possible.
Botswana is currently in the process pf implementing ICD-10 and the implementation is taking the South African Coding Training Standards into consideration.
As South Africa has implemented the internationally accepted ICD as the national diagnostic standard, questions regarding training standards and methods arise. This selection of examples demonstrates that the programmes proposed in South Africa are similar to current international best practice.
|This qualification has been developed for mobility across similar qualifications within the industry and is intended to allow for further learning towards higher level qualifications within this and other sectors.
This Qualification articulates horizontally with the following registered qualification(s):
This Qualification articulates vertically with the following registered learning programmes:
|CRITERIA FOR THE REGISTRATION OF ASSESSORS|
|For an applicant to register as an assessor, the applicant needs:
|As per the SAQA Board decision/s at that time, this qualification was Reregistered in 2012; 2015.|
|ID||UNIT STANDARD TITLE||PRE-2009 NQF LEVEL||NQF LEVEL||CREDITS|
|Core||263980||Analyse clinical information and assign ICD and Procedure Codes||Level 5||Level TBA: Pre-2009 was L5||10|
|Core||263977||Evaluate and assign ICD and Procedure Codes pertaining to diseases of body systems within the coding system||Level 5||Level TBA: Pre-2009 was L5||15|
|Core||263994||Evaluate and assign ICD and Procedure Codes pertaining to Other Groups within the coding system||Level 5||Level TBA: Pre-2009 was L5||10|
|Core||263974||Evaluate and assign ICD and Procedure Codes pertaining to Special Groups within the coding system||Level 5||Level TBA: Pre-2009 was L5||17|
|Core||263979||Utilise clinical coding terms, rules and conventions for diagnostic and Procedure Codes||Level 5||Level TBA: Pre-2009 was L5||8|
|Fundamental||252112||Demonstrate knowledge of the anatomy and bio-physical functioning of the human body||Level 5||Level TBA: Pre-2009 was L5||20|
|Fundamental||263981||Use coding resources to access information relevant to clinical coding||Level 5||Level TBA: Pre-2009 was L5||5|
|Fundamental||263975||Explain legal and ethical requirements for quality health information management||Level 6||Level TBA: Pre-2009 was L6||5|
|Elective||118010||Assess a medical claim||Level 4||NQF Level 04||8|
|Elective||118014||Explain the cycle of a medical claim||Level 4||NQF Level 04||2|
|Elective||119259||Explain the roles of actuaries, underwriters, claims assessors and reinsurers in Long-term insurance||Level 4||NQF Level 04||3|
|Elective||120303||Apply principles of risk management||Level 5||Level TBA: Pre-2009 was L5||8|
|Elective||244287||Conduct a baseline risk assessment and take appropriate action||Level 5||Level TBA: Pre-2009 was L5||7|
|Elective||15096||Demonstrate an understanding of stress in order to apply strategies to achieve optimal stress levels in personal and work situations||Level 5||Level TBA: Pre-2009 was L5||5|
|Elective||114278||Demonstrate and apply an understanding of the Labour Relations Act (Act 66 of 1995)||Level 5||Level TBA: Pre-2009 was L5||12|
|Elective||252110||Demonstrate knowledge of the structure and biology of micro organisms as it applies to clinical practice||Level 5||Level TBA: Pre-2009 was L5||12|
|Elective||244288||Demonstrate understanding of occupational health and safety legislation in the workplace||Level 5||Level TBA: Pre-2009 was L5||8|
|Elective||116948||Develop a programme that demonstrates effective ways of dealing with the effects of terminal and chronic illnesses, particularly HIV/Aids, in a workplace||Level 5||Level TBA: Pre-2009 was L5||12|
|Elective||117854||Facilitate meetings to deal with conflict situations||Level 5||Level TBA: Pre-2009 was L5||8|
|Elective||117874||Guide learners about their learning, assessment and recognition opportunities||Level 5||Level TBA: Pre-2009 was L5||6|
|Elective||15225||Identify and interpret related legislation and its impact on the team, department or division and ensure compliance||Level 5||Level TBA: Pre-2009 was L5||4|
|Elective||252105||Lead and participate in team approaches to health care||Level 5||Level TBA: Pre-2009 was L5||4|
|Elective||110526||Plan, organise, implement and control record-keeping systems||Level 5||Level TBA: Pre-2009 was L5||4|
|Elective||252102||Share information to promote effective decision making in health care||Level 5||Level TBA: Pre-2009 was L5||7|
|Elective||252098||Use communication skills to establish and maintain supportive relationships||Level 5||Level TBA: Pre-2009 was L5||6|
|Elective||13102||Apply the processes of planning and control as it relates to budgeting, standard costing and decentralised control||Level 6||Level TBA: Pre-2009 was L6||15|
|LEARNING PROGRAMMES RECORDED AGAINST THIS QUALIFICATION:|
|PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS QUALIFICATION:|
|This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.