Job responsibilities
Post Title:Clinical Coder
Pay Band:4
Hours:Full Time 37.5 hours per week
Department:Finance Directorate
Reports to:Clinical Coding Manager
Key Working Relationships:
Consultants and Clinical Staff, Ward Staff, Medical Secretaries , Health Records Staff, Information, Performance & Data Quality teams
Risk assessment:
Working with display screen equipment for prolonged periods of time
Exposure to disturbing photographs and casenotes, e.g. terminally ill patients or patients suffering abuse
Working under pressure to meet monthly deadlines
Job Purpose:
To abstract, analyse and accurately translate diagnostic and procedural information using the International Statistical Classification of Diseases and Related Health Problems (ICD10) and the OPCS Classification of Interventions and Procedures version 4in accordance with local and national rules and conventions. To support the Trusts business requirements and effective patient care by coding all inpatient episodes within monthly deadlines. Additionally, to liaise with clinical staff to address queries and locate and collate missing source material for coding purposes. To commit to life-long learning and embrace change.
Key Duties:
Using our trust EPR and scanned case notes, including letters, test results and operation sheets in conjunction with an understanding of medical anatomy and terminology, in order to verify the patients diagnoses and any procedures carried out during their inpatient episode of care, and correctly record them onto the patient administration system.
Use the Index and Tabular of ICD10 and OPCS4 in accordance with coding rules and conventions to accurate code the patients record. Use of judgment to translate complex cases where the diagnoses or procedures recorded is not readily codable, checking with an experienced coder or team leader.
Support the coding process by the successful navigation of the encoder to accurately and speedily code all inpatient episodes.
To communicate complex coding rules and conventions to clinical and administrative staff, external agencies and comment on local agreements under the supervision of the team leader.
Work on an individual basis and as part of a team to ensure monthly coding deadlines are met, in order to accomplish the Trusts internal and external information and business requirements.
Work towards learning to code all specialties including general, maternity and community coding, for the purposes of self-development, staff cover and to meet the monthly 5 day deadline, to ensure the Trust receives the full income for all activity carried out, as outlined in Payment by Results (PBR).
To liaise with medical / clerical staff in order to investigate and capture missing data items within the required timescale to ensure completeness of recorded data.
To report or resolve any patient episode errors as a result of cross-referencing with case notes to ensure patient data is accurate on the PAS system.
To attend internal and external Clinical Coding courses to attain and maintain clinical coding skills. On return to update coding books and feedback to Clinical Coding Auditor to ensure standardisation of Clinical Coding across the Trust.
To use the Clinical Coding books and manuals to support the coding process and keep up to date with Coding Clinics.
Demonstrate own duties to less experienced coders, referring any queries to Clinical Coding Auditor.
To work as a team covering all specialties and picking up lists during staff sick leave or annual leave.
To give advice regarding appropriate codes, ensuring any queries, which cannot be readily resolved, are referred onto the Clinical Coding Auditor or Clinical Coding Coordinator.
Other Requirements
To record data in manual and computerised systems in accordance with agreed policies and procedures.
To adhere to trust policies regarding confidentiality and information security.
To carry out any other duties commensurate with the grade of this job.
The duties defined in this job description are not definitive and may be subject to future amendments following appropriate consultation
Standard Clauses
The purpose of this post should remain constant, but the duties and responsibilities may vary over time within the overall role and level of the post. The post holder may from time to time be asked to undertake other reasonable duties. Any such changes will be made in discussion with the post holder in the light of service needs.
Competence
The post holder is responsible for limiting his / her actions to those which s/he feels competent to undertake. If the post holder has any doubts as to his or her competence during the course of his / her duties then s/he should immediately speak to their line manager or supervisor.
Codes of conduct
All employees of the Trust who are required to be registered with a professional body, to enable them to practise within their profession, are required to comply with their code of conduct and requirements of their professional registration. Those staff who are not required to be registered with a professional body are required to comply with the Trusts codes of conduct.
Confidentiality
The post holder must maintain confidentiality, security and integrity of information relating to patients, staff and other Health Service business.
Records Management
All employees of the Trust are legally responsible for all records that they gather, create or use as part of their work within the Trust (including patient, financial, personnel and administrative), whether paper or computer based. All such records are considered public records and all employees have a legal duty of confidence to service users. Employees should consult their manager if they have any doubt as to the correct management of records with which they work.
Health and Safety
Employees must be aware of the responsibilities placed on them under the Health and Safety at Work Act (1974) and the Manual Handling Operations Regulations (1992) and all relevant Trust Health and Safety Policies and Guidance. This ensures that the agreed safety procedures are carried out to maintain a safe environment for employees, patients and visitors to the Trust.
Infection Control
Employees must accept personal responsibility and accountability for Infection Prevention and Control practice. Employees should ensure they are familiar with, and comply with, all relevant Infection Control policies for minimising the risk of avoidable Health Care Associated Infection. All Employees must undertake annual mandatory updates in Infection Control.
Non Smoking Policy
The Trusts approach to smoking is in line with the governments on-going initiatives for an eventual smoke-free environment. It aims to adhere to the Worcestershire Health Community Campaign to help Worcestershire stop smoking.
A no smoking environment policy exists within all Trust premises including entrances and exits to hospital buildings and on other Trust property (with the exception of staff resident in staffresidences, as these are the homes of staff). In June 2014 a ban was implanted which meant staff, contractors and volunteers were no longer permitted to smoke in any of the hospital grounds, including car parks.
Further to this, The Alexandra, Kidderminster and Worcestershire Royal Hospitals, have all become smoke free to all patients and visitors as of 17 June 2015. This means that, as well as staff, members of the public, patients and visitors are not allowed to smoke in any of the acute hospital grounds, including car parks.
