HLTCCD007 — Undertake moderately complex clinical coding

1 Abstract clinical data from moderately complex patient health care records.

• 1.1Interpret and apply the Australian coding standards (ACS) to identify clinical data from moderately complex patient health care records.
• 1.2Select conditions, diseases or procedures for coding from moderately complex patient health care records.
• 1.3Identify principal diagnosis for admissions when coding from moderately complex patient health care records.
• 1.4Identify additional diagnoses for admissions.
• 1.5Identify interventions for admissions.

2 Assign codes to episodes of care relating to moderately complex patient health care records.

• 2.1Assign diagnosis and intervention codes according to current classification indices, standards and conventions.
• 2.2Determine sequencing of diagnoses codes according to current classification standards and conventions.
• 2.3Assign condition onset flag (COF).
• 2.4Determine sequencing of intervention codes according to current classification standards and conventions.
• 2.5Use resources to assist in making coding decisions.
• 2.6Complete process of assigning codes from moderately complex patient health care records.
• 2.7Review and validate Diagnosis Related Group (DRG) assigned to episode of care.

3 Clarify coding queries.

• 3.1Identify additional and missing information and clarifications required for accurate coding.
• 3.2Formulate written coding queries and forward to clinical health care professionals according to Australian Coding Standards (ACS) and Clinical Coding Practice Framework (CCPF).
• 3.3Make verbal enquiries with clinical health care professionals according to national guidelines and organisational policies, procedures and protocols.
• 3.4Refer unresolved issues concerning clarity and accuracy of the clinical documentation and data according to organisational policies and procedures.
• 3.5Identify administrative data factors required for coding including ventilation hours and neonatal admission weight.

4 Maintain coding resources.

• 4.1Address changes to data collection and coding requirements according to relevant standards, protocols and legislation.
• 4.2Amend data collection and coding activities in line with organisational policies and procedures.
• 4.3Identify and address own knowledge and skills gaps to ensure deficits are addressed.

5 Participate in coding audits.

• 5.1Identify and prepare patient health care records for coding audit according to organisational policies and procedures.
• 5.2Independently validate own coding and interpret and resolve coding error findings across moderately complex patient health care records.
• 5.3Participate in processes to review coding audit findings.

What does an assessment tool for HLTCCD007 need to cover?

To satisfy the Principles of Assessment and Rules of Evidence, an assessment for HLTCCD007 needs to address all 39 unit components: 5 elements with 23 performance criteria, 5 performance evidence requirements, 11 knowledge evidence requirements, and the foundation skills. A coverage matrix mapping each question and task to these components is what an auditor looks for.

How does Auditori generate an assessment tool for HLTCCD007?

Auditori pulls the current release of HLTCCD007 from training.gov.au and generates a complete package: candidate assessment, assessor guide with model answers and observation criteria, and a coverage matrix mapping every component. A suitably qualified person then reviews and approves the draft in a built-in workflow — consistent with ASQA's guidance on AI use in VET — before export as branded PDF and editable Word.

Is the first assessment tool really free?

Yes. Every new account includes one free credit — enough to generate the complete assessment tool for HLTCCD007 — with no card and no subscription required. After that it's pay-as-you-go per unit.

Can I check my existing HLTCCD007 assessment instead of generating a new one?

Yes — upload your existing assessment or learner guide and Auditori maps it against every element, performance criterion, PE and KE of HLTCCD007, showing exactly what's covered and what's missing. Mapping costs a quarter of a credit.