Objective
To be able to consistently assess the difficulty and complexity of coding of an episode of care. Statements such as moderately complex records have been used in training requirement documentation and this work seeks to clarify this requirement and support computer identification of cases which meet this need. This complexity is a tag on the episode which is used to select cases for practice or assessment.
It is necessary to be able to represent the complexity of a case so that
- Students have a consistent learning pathway – starting with the simple and moving to the more complex
- The expectation of coder competence for entry-level coders and more advanced coders is managed appropriately for students, employers, and examiners.
- Computers may accurately present cases of relevant complexity when establishing a group of cases to be coded for practice or assessment of competence.
Definitions
Moderately complex medical record may include:
- single condition reason for admission but with the existence of co-morbidities and/or the need for multiple interventions
- multiple conditions reason for admission without comorbidities or the need for interventions
- episodes as defined by national or jurisdictional guidelines.
Source: 22274Vic_Certificate IV 2014
Note: this is not a definition which the computer can assess – there is a need to establish computer-based rules which support the selection of cases which meet these criteria.
Note: for future use and use in hospitals where more extensive skills are needed, it is necessary to identify additional more advanced complexity levels.
Note: additional requirements associated with complexity are indicated in the complexity level table which reflects the difficulty associated with learning and skill representation, such as the application of standards and complex sequencing.
Principles
There is a need to be able to select complexity and build towards the moderately complex and beyond. Therefore, the complexity levels begin with the very simple and move into more complex requirements.
Complexity Levels
Note each level includes codes which meet lower levels of complexity plus the specified requirements for the level defined.
The maximum number of codes is used to indicate complexity but also as it impacts the time it might take the code the case. For a random selection of cases to be fair a range of size of cases is needed as coding is timed and each code system/country may determine their speed requirement to consider a coder as competent. For example, in Australia, a coder is required to meet the minimum speed of 6 records an hour (as an average)
Note: introductory coding courses (getting students started with the basics) are expected to cover content at levels 1, 2 while more advanced coding incorporates levels 3 and 4, and 5.
Level 6 episodes are highly suited to class discussion rather than assessment.
| Level | Description | Objective | Minimum / Maximum number of | |||
| Diagnosis Codes | External Causes | Procedures | Additional test components (e.g. COF) | |||
| 1 | Test of coding conventions only | Cases where the use of the index and tabular list is ALL that is required to obtain the correct code (diagnosis or procedure) For example: admission for unspecified asthma (no other information or coding required). | Min 1 | Max 0 | Min 0 | Not included |
| 2 | Overarching principles | The correct allocation of the code should require correct use of lead terms and Ability to correctly interpret standards for – principal diagnosis, (including correct coding or not to code symptoms) – additional diagnosis and – inclusion of procedures including anaesthesia – Inclusion of common additional codes such as smoking status – Simple (single cancer coding without secondaries) – Simple external causes – Simple single | Min 1 Max 3 | Max 0 | Min 0 Max 3 | Not included |
| 3 | Include injuries and common day stay administration codes | Code complications which may change the code Codes from chapters 19 and 12, with external causes etc Use of ‘’other’’ – understanding when this should be used Code sets such as Dagger/asterisk, cancers Cancelled procedures Application of coding standards for these cases Diabetes without complications Administrative coding such as admission for chemotherapy. | Max 6 | Min 0 Max 1 | Min 0 Max 6 | Included |
| 4 | Moderately Complex | The single reason for admission with co-morbidities and /or the need for multiple interventions. Include conditions which require the use of the first essential modifier when looking up codes in the index. Diabetes and related conditions Multiple injuries (single cause) Complications within the episode of care Revision procedures Supplementary conditions Allied health interventions Requires medical vocabulary and clinical knowledge and application of clinical knowledge for look up and understanding Application of coding standards and rules correctly Sequencing required to avoid duplication of diagnosis codes. | Min 2 Max 10 | Min 0 Max 1 | Min 0 Max 10 | Included |
| 5 | Highly complex | Full range of conditions Full range of medical and surgical complications Multiple injuries or accidents (multiple causes) Intensive care with ventilation | Unlimited | Unlimited | Unlimited | Included |
| 6 | Requires documentation | Ability to document the rationale for coding query and debate | Unlimited | Unlimited | Unlimited | Included |