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The Coding Process
The source document for coding in Ireland for HIPE is the medical record or chart. The clinical coder, the person who translates medical terminology into alpha-numeric code, performs an essential function in providing quality, accurate, and uniform medical information and greatly contributes to the continuous growth of medical knowledge. In addition to the discharge summary or letter, additional documentation referenced for coding a case include; nursing notes, consultation reports, progress notes, operative reports, pre- and post-operative reports and pathology reports. The clinical coder, following The 5 Steps to Coding Quality, uses the entire chart to extract the conditions and procedures to draw an adequate picture of the patient and their health care encounter.
Data Quality, Audit and Training
The Clinical Coding Support Team in the HIPE Unit provides data quality, audit and training to all HIPE Coders in Ireland. They also provide education and support to HIPE users on all aspects of the system.
Coding Classification used in Ireland
ICD-10-AM / ACHI / ACS
ICD-10-AM is the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification. The ICD-10-AM disease component is based on the World Health Organisation (WHO) ICD-10. ICD-10-AM is used in conjunction with the Australian Classification of Health Interventions (ACHI), and the Australian Coding Standards (ACS) to reflect an accurate health episode of care. The 4th edition of this classification was introduced for all discharges from 1st January 2005 and was selected as the best integrated coding scheme for diagnoses and procedures available internationally. Ireland updated to the 6th Edition of ICD10-AM/ACHI/ACS for all discharges from 1st January 2009. For further details please see the Classification section.
If you are a HIPE clinical coder and have a specific coding query, please complete the downloadable Coding Query Help Form which can be returned via post, fax or email.