Clinical Coding System
Definition:
A clinical coding system is software that facilitates the translation of health records into systematic classifications of medical diagnoses, procedures, resources consumed and other relevant clinical content into standardised codes, enabling accurate documentation, billing, and statistical analysis in healthcare settings.
Standards and specifications
General requirements
Cyber security
The software must demonstrate ability to effectively achieve mitigation strategies in line with ‘Essential 8’.
Privacy
Data collected in clinical coding system constitutes health information. Due to the sensitive nature of this information, it generally has a higher degree of privacy protection than other personal information, under relevant federal, state and territory legislations.
The software must demonstrate adherence to relevant federal, state or territory privacy legislation for example, the Privacy Act 1988 (Federal) or Health Records and Information Privacy Act 2002 (NSW).
The applicable federal legislation is the Privacy Act 1988.
Details of the relevant state and territory legislations are contained under the State and territory requirements section below.
Core requirements
Australian Core Data for Interoperability (AUCDI)
The software should support the use of AUCDI Release 1.
Note: The focus of the AUCDI Release 1 is the representation of the clinical content necessary for each of the data groups identified within the Release 1 scope.
Development is continuing to enhance AUCDI.
Standards for terminology, code sets and classifications
The system should:
- support Systematised Nomenclature of Medicine-Clinical Terms AU (SNOMED CT-AU)
- support ICD-10-AM/ACHI/ACS classification system
- support the Australian Refined Diagnosis Related Groups (AR-DRG) classification
- support Standardised Pathology Informatics in Australia (SPIA)
- support Logical Observation Identifiers Names and Codes (LOINC®)
- support Australian Medicines Terminology (AMT)
- be capable of using METEOR for recording clinical information with data specifications
- be capable of using Nutrition Care Process Terminology (NCPT) (Dietary)
- support Rapid Response System (RRS) terminology
- support the National Clinical Terminology Service (NCTS).
State and territory requirements
The following state and territory requirements must be upheld based on location.
| State | Theme | Link |
|---|---|---|
| ACT | Privacy | Health Records (Privacy and Access) Act 1997 (ACT) |
| Territory Records Act 2002 (ACT) | ||
| Information Privacy Act 2014 | Acts | ||
| NSW | Privacy | NSW Privacy Laws |
| NT | Privacy | Refer to Federal requirement |
| QLD | Privacy | Privacy legislation in Queensland |
| SA | Privacy | Refer to Federal requirement |
| TAS | Privacy | Refer to Federal requirement |
| VIC | Privacy | Privacy and Data Protection Act 2014 |
| WA | Privacy | Refer to Federal requirement |