Higher Certificate in Diagnostic and Procedural Coding

Purpose

The Higher Certificate in Diagnostic and Procedural Coding has a strong industry-oriented focus, it will develop the foundational skills, knowledge, attributes and applied competencies of the learner to enable them to render service as a Clinical Coder in the Healthcare industry, both in the public and private sector.

The qualification emphasises selected general principles linked to more pacific procedures and its application. The learner will be equipped with the knowledge, skills, attributes and competencies to perform: Diagnostic and procedural coding, data collection, researching information, supervision of data collection, data auditing, data capturing and elementary data analysis. Qualifying learners will be able to systematically access, critically analyse and evaluate existing knowledge in the field of Clinical Coding.

Upon completing the qualification, qualifying learners will be able to

• Assess health records to abstract diagnosis and procedures and accurately assign International Statistical Classification of Diseases (ICD) and related diagnostic and procedural codes.
• Apply the rules and conventions of diagnostic and procedural codes.
• Apply the World Health Organisation and South African Coding standards, rules and guidelines when coding.
• Demonstrate an understanding of the legal and ethical requirement when assigning codes and its applicability to health information systems nationally and internationally.
• Explain the rules, conventions and guidelines of the ICD-10 Diagnostic and CCSA Procedural Coding and the South African Coding Standards.
• Assess health records to extract diagnoses and recorded procedures and accurately assign ICD-10 and Procedural Codes.
• Explain the legal and ethical requirements and implications associated with assigning Diagnostic and Procedure Codes to health information systems.

Rationale

After consultation with the representatives of the coding industry, the need for this qualification was identified as well as the competencies expected from the qualifying learners exiting the qualification.

Diagnostic and procedural coding is mandatory in healthcare for the healthcare professional. Over and above the cognitive, psychomotor and affective skills required within healthcare, each specific field has a unique body of cognitive, psychomotor and affective skills where the Diagnostic and Procedural codes are mandatory.

There is a critical skills shortage of qualified/accredited clinical coders in the South African healthcare environment. This entry-level qualification provides access to clinical coding and creates a career path for these learners in the healthcare industry, in both the public and private sector. This qualification will also help to contribute to a quality hierarchy of skills required to provide quality health data in the healthcare industry. The qualification is designed to enable learners to pursue further personal and professional development and to promote life-long learning within clinical coding and related fields.

The qualification has a practice focus, was designed for the improvement of healthcare efficiency and to create an entry point and pathway for learners who wish to pursue a career in clinical coding. The qualification provides the worker, in the South African healthcare environment, with the opportunity to gain ICD coding knowledge and skills and promotes the healthcare worker to apply code accurately, to identify gaps in work practice, to think independently and creatively and to propose interventions within the chosen focus area. This will ensure fair reimbursement for healthcare services rendered and ensure data is communicated in a predictable, consistent and reproducible manner as is required by the coding industry.

Recognition of Prior Learning (RPL)

RPL is applicable for entry selection within the context of the institutional policies and guidelines. The RPL process will incorporate a holistic approach and comply with the current regulations of SAQA and the CHE. The learner has the right to have previous experience and qualifications taken into consideration when applying to do further qualifications.

Learners may be granted access through RPL. Evidence of prior learning must be provided employing a portfolio and other forms of appropriate evidence of challenging theoretical and clinical examinations. Clinical and work-based experience must be relevant to the qualification the learner is applying for.

The assessment(s) will be done by a registered assessor and a registered moderator will validate the assessment process.

Credit transfer may be granted according to current institutional policy and guidelines of the relevant statutory health council, the CHE and SAQA. Credit accumulation transfer will only be considered for a learner who completed an accredited and registered qualification. The credits transferred must be on the same level of the module the credits are transferred towards; content and outcomes of the module(s) correspond with the module(s) presented by the institution and the learner passed the additional assessments, if required. All credits transferred will be submitted as part of the completion of training/academic records. Thus, all transcripts will reflect exemptions achieved through CAT as well as the credit points.

Entry Requirements

The minimum entry requirement for this qualification is

• National Senior Certificate, NQF Level 4 granting access to Higher Certificate studies.

Or

• National Vocational Certificate, NQF Level 4 granting access to Higher Certificate studies.

Or

• Senior Certificate, NQF Level 4.

This qualification consists of the following compulsory modules at National Qualifications Framework Level 5 totalling 120 Credits.

Compulsory Modules, Level 5, 120 Credits

• Foundations of Professional Practice, 5 Credits.
• Fundamentals of Clinical Coding, 5 Credits.
• Anatomy, 10 Credits.
• Physiology, 10 Credits.
• Diagnostic and Procedural Coding, 60 Credits.
• Health Information Science, 30 Credits.

1. Demonstrate knowledge of 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. Identify the legal and ethical requirements and implications associated with assigning Diagnostic and Procedure Codes to health information systems.

Associated Assessment Criteria for Exit Level Outcome 1

• Analyse the different sections found in each of the ICD and Procedural Volumes to reflect their uses for a specific purpose, but are not limited to ICD Volume 1, 2 and 3, all Volumes for Procedure Coding.
• Apply the use of the lead term and conventions in the Volumes when assigning the relevant code to identify specific clinical information.
• Analyse and evaluate the structure of allocated/assigned ICD and Procedure Codes in terms of their implications on coding and health information.

Associated Assessment Criteria for Exit Level Outcome 2

• Utilise the different classifications when assigning a Clinical Code to extract the appropriate code.
• Apply and allocate the principles of primary and secondary diagnoses according to ICD and Procedure Codes.
• Record the allocated ICD and Procedure Codes according to the specific organisational requirements.

Associated Assessment Criteria for Exit Level Outcome 3

• Evaluate the impact of coding on health information data according to the specific organisational requirements to reflect trends in diseases and procedures.
• Identify and apply legislation relevant to health information management in the process of Clinical Coding.
• Handle health information following legal and ethical requirements to ensure the maintenance of patient confidentiality at all times.
• Explain the uses of clinically coded data to reflect the benefits for the healthcare industry in South Africa.

Integrated Assessment

The institution's qualification and subject policies will be followed to assess learners. The aim is to establish a learning environment to allow an interactive learning process to ensure learners achieve the desired outcomes and can demonstrate competence, in a practical context, against all the specific outcomes contained in the unit standards and their associated assessment criteria, theory and critical cross-field outcomes.

Work-integrated learning underpins the teaching and learning of learners and thus workplace concerns are integrated into the classroom, simulation laboratory and workplace leaning. Learners spend time in the workplace, as part of their credit-bearing hours to complete the required Portfolio of Evidence (PoE) which form an integral part of learner assessment.

Assessment will be formative and summative as specified and aligned to teaching to reflect work-based integration leaning. Various forms of assessment will be used. The integrated assessment comprises of formative and summative assessments which will include cognitive, psychomotor and affective aspects.

Formative assessment may be given through case presentations, assignments, Portfolio of evidence (PoE), tests (written and electronic), reflective journaling, oral presentations, questioning, practical demonstrations and clinical assessments; and direct observation in simulated and/or controlled work environment.

The summative evaluation may be made through

• Portfolio of Evidence (PoE).
• Written and oral examinations.

Learners must obtain at least 50% in a system of continuous assessment, for each module, except Module 5. For this module 80% is required to obtain examination admission. This is an international standard. Marks will be captured using the official procedures provided by the institution. Learners' disputes and appeals in terms of assessment results will be settled using the relevant institution's policy and procedures.