This is the author version of article published as:
McKenzie, Kirsten and Walker, Sue and Dixon-Lee, Claire and Dear, Gareth and
Moran-Fuke, Judy (2004) Clinical coding internationally: a comparison of the coding
workforce in Autralia, America, Canada and England. In Proceedings 14th
International Federation of Health Records Congress, Washington.
Accessed from http://eprints.qut.edu.au
CLINICAL CODING INTERNATIONALLY: A COMPARISON OF THE CODING
WORKFORCE IN AUSTRALIA, AMERICA, CANADA AND ENGLAND
Authors: Kirsten McKenzie1, Sue Walker1, Claire Dixon-Lee2, Gareth Dear3, Judy Moran-Fuke4
Presenters: Sue Walker1, Claire Dixon-Lee2, Gareth Dear3, Judy Moran-Fuke4
1National Centre for Classification in Health, Brisbane, Australia
2American Health Information Management Association, Chicago, USA
3National Health Service Information Authority, Birmingham, England
4Canadian Health Information Management Association, Ontario, Canada
Recently, researchers in Australia, America, England and Canada have conducted national surveys
of clinical coders in their respective countries. In Australia in 2002, the National Centre for
Classification in Health (NCCH) in collaboration with the Health Information Management
Association of Australia and the Clinical Coders’ Society of Australia conducted the National
Clinical Coder Workforce survey, a study of clinical coders and coding managers1. In America in
2002, the American Health Information Management Association (AHIMA) commissioned an
independent national workforce research study to the Centre for Health Workforce Studies
(CHWS), State University of New York at Albany to provide a picture of health information
management roles today and forecast through 20102. In England in 2003, the National Health
Service Information Authority (NHSIA) conducted a national clinical coder survey, along with a
survey of coding managers, in a similar format to that completed by Australia3. In Canada, in 2002,
a study was conducted by the Canadian Health Record Association (CHRA) (currently known as
the Canadian Health Information Management Association (CHIMA)) and Thiinc iMi, which
provided information regarding the various roles health record professionals have in the healthcare
sector, the qualifications of health record professionals and their salaries4.
While these surveys have been conducted independently, they have addressed similar issues in
terms of coders' salaries, educational backgrounds, roles and responsibilities, resources, experience,
and continuing education needs. While several papers/reports have been generated from the
individual research at a national level, there has been no systematic comparison of the coder
workforce at an international level to date. This paper will describe the findings of each of the
national surveys, and seeks to identify similarities and differences in important aspects of the coder
workforce at an international level.
The Australian Clinical Coder Workforce
The National Centre for Classification in Health, in collaboration with the HIMAA and the Clinical
Coders' Society of Australia, developed a follow up survey to a 1994-5 nationwide survey of
clinical coders with the aim of quantifying the changes that have occurred in the coder workforce
over the last eight years. There were five broad issues addressed in the survey:
What do coders do?
Where is coding done?
How is coding done?
How are coders supported?
A total of 1277 surveys were sent to eligible facilities in July 2002. Of the 1277 facilities contacted,
a total of 424 managers responded to the survey, representing a 33.2% response rate. The number of
coders to respond to the survey was 1031.
Around 90% of coders worked in a hospital facility and 65% of coders indicated that they worked
in the public sector. Over half of the respondents stated that their position titles were clinical coders,
followed by 31%, who identified their positions as Health Information Managers.
American Health Information Management Association Members Survey
In the United States in 2002, the American Health Information Management Association (AHIMA)
commissioned an independent national workforce research study conducted by the Center for
Health Workforce Studies (CHWS), State University of New York at Albany. The AHIMA member
survey aimed to gather information about the membership of AHIMA and about the HIM
workforce. A summary of findings specific to clinical coders was prepared by MacKenzie5 in 2003,
and the results reported in this paper reflect these findings, in order to allow comparability to the
other international surveys of clinical coder workforces.
Over 10,000 surveys were sent to a random sample of AHIMA members with responses received
from 5,333 members, representing a 55% response rate, the highest response rate of any of the four
countries. Almost 30% of respondents identified themselves as being coders or clinical data
Over 60% of coders who responded worked in hospital inpatient settings, 18% in hospital outpatient
facilities, and 7% in clinician’s offices, suggesting that respondents to the AHIMA survey were
more varied in terms of their places of employment compared to Australian respondents, the
majority of whom worked in hospital facilities.
The English National Clinical Coder Workforce
The English National Clinical Coder Survey was developed with the aim of generating baseline
information on the clinical coding workforce within the English National Health Service (NHS),
highlighting their employment patterns and continuing education needs.
A total of 307 NHS Trusts were asked to participate in the survey. 106 Trusts returned managers’
surveys representing a response rate of 34.5%. A total of 737 coders responded to the survey, with
9% of responses received from Specialist Trusts, 21% from Acute Teaching Trusts, 56% from
Acute Trusts, 8% from Mental Health Trusts, 1% from Community Trusts, and 4% from Primary
Care Trusts. This represented similar numbers of coders working in hospital facilities to the
The Canadian Survey of Health Record Professionals
In an effort to provide an illustration of the current Health Record professional landscape to further
guide the Canadian Health Information Management Association (CHIMA) in generating a national
strategy for the profession, CHIMA and THiiNC Information Management Incorporated (THiiNC
iMi) developed Taking Stock, a national survey of Health Record Professionals. Specifically, the
survey was designed to:
Develop a snapshot of the current health record environment across the country;
Quantify national health records human resource issues;
Identify key strategic priorities for the health record community;
Provide an opportunity for CHIMA and THiiNC iMi to collaborate, and
Develop publications to inform and influence the debate on current issues in the
health record environment.
The survey was designed for all institutions and agencies that employ Health Record Professionals.
It was divided into six sections; survey respondents were asked to complete questions on the
Supply and demand;
The Electronic Health Record (EHR);
Data quality, and
Of the 800 surveys that were mailed, 157 were completed and returned. This was a 19.6% response
rate, representing the lowest response rate of all four countries. Almost 90% of surveys were
received from hospitals and over 75% of survey respondents were employed in a rural setting.
What Is A Coder?
Australian Clinical Coders
In Australia, clinical coders are responsible for allocating ICD-10-AM codes to diagnoses and
procedures as part of their work, and the process of coding refers to the tasks of allocating ICD-10-
AM codes using books or an encoder, data entry or indexing of codes, checking of coding edit
reports, updating coding books, quality assurance activities relating to coding, participating in
meetings to discuss coding issues, or any other activity related specifically to coding.
Coders in Australia generally have one of three professional backgrounds. Some coders have
qualifications in Health Information Management from one of four universities in Australia which
offer this program. Each undergraduate program offers a significant component of clinical coding
and related subjects (medical terminology, medical science, anatomy and physiology) as part of the
core HIM curriculum. Graduate HIM coders often participate in other activities relating to the
management and administration of the medical record or health information service within their
hospital of employment, although they may also choose to code exclusively.
The HIMAA also offers educational courses for clinical coders. Both medical terminology and
various skill levels of clinical coding courses (introductory, intermediate, and advanced) are offered
by the Association through its distance education program and this training avenue provides a
significant source of education for practicing coders. There is no pre-requisite knowledge or
previous educational attainment required to enrol in an HIMAA medical terminology distance
education program although it is necessary to have completed the medical terminology component
or demonstrate skills in this subject before the coding subject is undertaken.
Other coders may not have received formal education in coding, but have been taught to code ‘on
the job’ through either a structured educational program offered by their hospital or hospital group
or informally one-on-one with another coder. Coders without some form of formal education in
coding are becoming less common in Australia.
American Coders/Coding Specialists
According to the AHIMA Certified Coding Associate (CCA) outline, used as the basis for the
development of the CCA examination, US coders require competency in the following activities:
coding with ICD-9-CM and CPT/HCPCS
conduct of coding validation and quality studies
abstracting information for coding from health record and other pertinent data sources
qualitative assessments of source documentation
adherence to facility’s health information services regulatory requirements
validation of reimbursement system code assignments
collection of data for severity of illness assessments
assistance in interpretation and use of coded data for strategic planning and reporting.
In the US, the AHIMA offers coding certificates in the following categories:
CCA (Certified Coding Associate) – entry level
CCS (Certified Coding Specialist) – intermediate/advanced level
CCS-P (Certified Coding Specialist – Physician office) – intermediate/advanced level
Eligibility to sit for the AHIMA Coding Certificates is based on demonstrated knowledge and
experience. Formal coding education is not required, but is recommended for novice coders.
The AHIMA offers a model coding curriculum approval program for certificate programs, with
a formal approval process to assure that programs meet the model curriculum criteria.
Healthcare organizations in the US indicate that an AHIMA coding credential is either desirable
or required in some cases, for employment.
English Clinical Coders
In England, clinical coders undertake abstraction, analysis and translation of complex clinical data
into codes following the rules and conventions of ICD-10 for diagnoses and OPCS-4 for procedures
using coding manuals or encoders. The resultant codes are input into hospital computer systems.
For employment as a clinical coder in England, most hospitals require General Certificates of
Secondary Education (GCSEs) and a good standard of English language; medical terminology
experience is desirable but not essential. In 1999 the National Clinical Coding Qualification (UK)
was introduced, with the recommendation that all coders should pass the exam. Since the National
Clinical Classifications Service introduced its training service in 2002, there has been an increased
uptake in the number of new coders who have had formal foundation course training. Continued
professional development in clinical coding is through attendance at meetings and workshops.
Canadian Health Record Technicians/Professionals
In Canada, coders are responsible for allocating ICD-10-CA/CCI codes to diagnoses and procedures
using a Folio software product. The Folio product is a computerized program which eliminates the
need for coding books. The coders also check reports that are returned, either online or in paper
format, from the Canadian Institute of Health Information (CIHI). They are responsible for quality
assurance activities related to coding, participating in meetings to discuss coding issues and any
other activities related to coding.
A coder can gain their education from a community college, a university program or from a
program offered by the Canadian Healthcare Association. All programs are reviewed and approved
by CHIMA. Once a potential coder has graduated from one of these approved programs, they are
qualified to write the certification exam set by CHIMA. A “laddering program” exists which a
health information management professional, such as a health record technician or health record
administrator, can enter the third year of a four year program and when the candidate passes,
receive a bachelors’ degree in health information management. Today, Canada has only one
category of HIM graduate – a health information management professional. The previous health
record technician and health record administrators still exist but these practitioners are encouraged
to upgrade their skills.
Summary of Hospital Discharges
In order to provide an illustration of the challenges faced by coders in hospital facilities in each
respective country, a summary of the number of hospital discharges is provided:
Australian hospitals recorded almost 6.4 million discharges in the 2001/2002 financial year6.
Hospitals in the USA registered approximately 32.7 million discharges in 20017.
Hospitals in England recorded around 12.7 million finished consultant episodes in the
2002/2003 financial year8.
Canadian hospitals reported over 2.3 million discharges in 20029.
Clinical coders are responsible for assigning disease and procedure codes to represent the morbidity
experiences of patients for each of these discharges.
One-third of Australian coders worked full-time, nearly 30% worked part-time (with fixed working
hours), almost 10% worked casually (variable working hours), and the remaining 30% had other
work to do besides coding.
Half of the English respondents were employed on a full time basis with no additional work other
than clinical coding, and 46% were employed part time with no additional work other than coding.
In the US, 10% of coders are employed part time, 87% on a full time basis and 3% are paid a per
American and English coders had different employment patterns to Australian coders with
considerably higher percentages of coders employed solely to code, either on a full-time or part-
time basis. Data was not available on employment status for Canadian coders.
Approximately 36% of Australian coders indicated that they had attained a Bachelor’s degree in
health information management/medical record administration (HIM/MRA). The HIMAA distance
education course was the third most common (28.7%) method that respondents used to learn to
code. A significant number of coders (10%) said they had no formal coding education beyond what
they learned on-the-job.
Almost 60% of American coders had an Associate Degree, 22% held a Bachelor’s degree, 18% had
no further education beyond high school and 1% attained postgraduate qualifications. Nearly 60%
of AHIMA credentialed coders held an RHIT (Registered Health Information Technician), a further
14% held an RHIT with mastery level coding credentials (such as a CCS or CCS-P), 16% held an
RHIA (Registered Health Information Administrator), and 9% held a CCS/CCS-P only.
Nearly 14% of English coders indicating that they had not undertaken any formal training in coding,
and 41% indicating that they had not undertaken any formal refresher training in coding.
Over 20% of Canadian coders had a certificate or technical diploma, while less than 5% of
employees had baccalaureate or master’s degrees. Among Canadian survey respondents, the Health
Record Technician designation (49% of employees) was twice as common as a Health Record
Administrator/Health Record Professional (HRP) designation (22% of employees).
Almost twice as many coders in America indicated that they had no further education beyond high
school compared to Australian coders. However, around four out of five American coders held
tertiary qualifications compared to just over half of the Australian coders. Slightly more English
coders had no formal coding training compared to Australia. Considerably fewer coders had tertiary
qualifications in Canada than in Australia or America. Some of these findings may be due to timing,
with most countries now engaged in offering formal education for clinical coders which was not
available in the past. This is likely due to the wider use of coded health data for a variety of
purposes, including reimbursement, research and health care management purposes. There is greater
emphasis on ensuring that coders are competent and that the codes accurately reflect health care
experiences of patients.
Salary and Industrial Conditions
Salaries from each country were converted into a common currency ($USD) (using Purchasing
Power Parity Conversion Factors10) to adjust for cost of living differences (Note: This common
currency has been used for all figures in this section).
The average annual salary of FTE Australian coders overall was in the range $25 000–$28 570.
Salaries for Australian coders increased slightly by years of experience with coders with less than
one year of experience earning around $23 214, rising to around $26 785 for coders with more than
one year of experience. Furthermore, Australian coders who reported that they held tertiary
qualifications and HIM/MRA degrees had annual salaries around $28 571 to $32 142, compared
with coders who had completed non-tertiary HIMAA education courses who generally earned in the
range of $21 428 to $24 999.
The average annual salary of American clinical coders was approximately $37 000, with coders
with an RHIT and mastery level coding credentials attaining the highest average annual salary of
over $40 000 USD.
The average salary for a full time English clinical coder was in the middle two ranges $16 867-$19
577 (29% of coders) and $19 578-$23 750 (28% of coders) per annum which equates to the English
A&C grade 3 and 4 respectively. There was an increase in the salaries of English coders as coders
become more experienced, with clinical coder with less that one year’s coding experience earning
an average of $1428 per annum less than clinical coders who had been coding for 1-2 years,
increasing by around $4285 per annum for coders with more than five years experience.
According to Canadian survey responses, the average annual salary of Health Record
Administrators (HRA’s) was approximately $32076 per annum and the average annual salary of
Health Record Technicians (HRT’s) was approximately $26153 per annum.
Comparing average salaries, American coders earn approximately 30% more than Canadian and
Australian coders, and approximately twice as much as English coders. Canadian and Australian
coders earn similar salaries, which are around 30% more than English coders (See Figure 1). In all
four countries, higher credentials and/or more years of experience translate into higher salaries for
coders. (America $37000, Canada $28846, Australia $26785, England $19571)
Figure 1: Average salaries of coders internationally (in $USD)
Anecdotally, coders report that they are being asked to do more work but that there are insufficient
coders to meet demand. This was explored by looking at the number of reported vacancies for
coders and the number of new coder positions being created as reported in each survey.
Looking at hospitals as the location for coder employment, around 10% of Australian facilities
indicated that there were vacant positions for coders, with a total of 38.1 FTE coder positions
available. This is an average of almost one vacant position within each of these sites.
Approximately 96% of American coders reported that there were some or many jobs available in
their hospitals. In addition to hospital vacancies, in the US, there are also a significant number of
vacancies in rehabilitation facilities, home healthcare agencies, government agencies, managed care
organisations and insurance companies for health information management personnel trained in
coding. The national vacancy rate for clinical coding and billing personnel is over 8%, with 40% of
hospitals reporting difficulty recruiting coding and billing staff, according to a 2002 American
Hospital Association study11. 27% of managers in England indicated that there were vacant
positions for coders, with a total of 46 coder positions available. Seventeen per cent of Canadian
survey respondents reported a vacancy in the coding/abstracting area. The average vacancy was 1
individual per site. The only other vacancies of note were in the decision support/data analysis and
supervision/management roles; 4.3% of respondents reported vacancies in each of these positions.
The average vacancy for these positions was 1.2 and 1.0 per site respectively.
A similar number of vacancies were reported in the Australian, English and Canadian surveys, with
around 40 vacant coder positions in total available, however when considering the number of
discharges that coders are required to manage, it is obvious that the coder shortage in England is the
most acute, followed by Australia and Canada. While the actual number of coder positions available
in America was not provided, it can be assumed that with approximately 20% of institutions
reporting vacancies, unfilled coder positions in America vastly outnumber those in the other three
Two-thirds of Australian clinical coders, nearly 90% of Australian Health Information Managers
and 95% of ‘other’ coders indicated that they performed duties beyond the defined role of a coder.
The most common task overall that Australian coders performed besides abstracting information
from records and allocating codes, was quality assessment, with two-thirds of coders performing
Only 4% of English coders indicated that they had other work to do besides clinical coding, and
these tasks were specified as follows: data entry work other than coding, health record duties, ward
clerk duties, and reception duties.
In addition, coders in both countries were asked if they were involved in other areas which
impacted on their clinical coding role. Over 28% of English coders stated that they regularly liased
with the IT department (compared to 40% of Australian coders), 9% of English coders were
involved in organising or conducting continuing education activities (compared to 23% of
Australian coders), 6% of English coders undertook analysis of hospital information (compared to
23% of Australian coders), and 5% of English coders were involved in software testing (compared
to 21% of Australian coders). In the US, in addition to abstracting and coding from each medical
record, about 30% of coders are also required to analyse and abstract information from the hospital
record for other database systems, and regularly discuss coding issues with clinical staff.
It appears that coders in Australia are required to perform considerably more varied tasks beyond
clinical coding compared with English and American coders. Data was not available on non-coding
tasks for Canadian coders.
Coding throughput is a measure of the average number of records that a coder is required to code in
a defined time period – per day or per month, for example. It is recognised that there are a number
of factors that influence coders’ ability to meet specified targets, including a hospital’s casemix,
severity levels of the patient’s diagnoses and procedures and the subsequent complexity of the
medical record, plus the number and type of ‘non coding’ tasks that coders are required to perform.
Recognising that it is virtually impossible to create a standard measure of coding throughput, this is
nonetheless an area of significant interest to managers of coding services. We report here the
information submitted by clinical coders in response to the national surveys, without any attempt to
create benchmarks of coding performance, either nationally or internationally.
Forty-four percent of Australian coders indicated that they were required to meet a coding
throughput target. Note that, in this country, only inpatient and day surgery discharges are currently
coded – outpatient and Emergency Room attendances are not coded. The average daily throughput
requirement was specified as 28 records per standard working day (3–4 records per hour). However,
the coding throughput mode was slightly higher at 30–39 records per day (4–5 records per hour).
Nearly 83% of English coders indicated that they had clinical coding targets to meet, with 55% of
these coders stating that they had to have a 95-100% completion rate of coding episodes by the end
of the month.
When asked about coding productivity, over 80% of Canadian respondents stated that they did not
have standards for coding productivity. For those inpatient facilities that did have standards for
coding productivity, the average coding target was 23.5 records per day for inpatient records. Other
informal standards are 80 records per day for Emergency coding and 50 records a day for Same Day
Surgery coding. At 23.5 records per day, the throughput requirement is slightly lower than the
Australian throughput requirements of between 30 and 40 records per day.
Dunn and Mainord (2001)12reported average coding productivity requirements in the US:
30 minutes per record for inpatient records
8.5 minutes per record for observation, ambulatory surgery, and minor procedure records
3.3 minutes per record for outpatient tests
4.2 minutes per record for Emergency Room visits.
Assuming an average working day of 8 hours, this is an average of 16 inpatient records per day for
US coders, less than the requirements reported by Australian and Canadian coders. The impact of
coding accuracy and regulatory compliance related to healthcare reimbursement contributes to this
time factor in the US.
English coders were almost twice as likely as Australian coders and four times as likely as Canadian
coders to have coding throughput requirements.
Because of the variety of uses to which coded morbidity data is put, including providing support for
clinical and management decision-making, health services and public health research and funding
initiatives, there is also considerable interest in the quality of the coding upon which such decisions
are based. Both Australian and English coders considered a list of factors that may have an impact
on the accuracy, completeness, and timeliness of coding, and indicated the severity of each factor
on a scale from no impact to an enormous impact.
For Australian coders, the factor considered most likely to affect coding quality was incomplete
medical record content, with 77% of coders stating that this factor had an impact. This was closely
followed by principal diagnosis not being identified (74%), complications /comorbidities not being
identified (71%), illegible medical record entries (69%), and pressure to maintain coding throughput
The factor considered most likely to affect coding quality according to English coders was
incomplete medical record content, with 87% of coders stating this factor had an impact. This was
closely followed by illegible medical record content (85%), and principal diagnosis not being
identified (83%), and complications /comorbidities not being identified (78%).
Canadian respondents were asked to rank coding quality challenges in their department. Chart
documentation/completion issues were cited as the biggest challenge, followed by technology
issues, coding quality, EHR, recruitment and staff retention. Since the Canadian survey was done,
there have been two data quality studies in various provinces that have reviewed coding and
developed recommendations. These studies verified the documentation/completion issues but also
showed wide variances between small hospitals and large and/or teaching hospitals.
In a study in 199413, which surveyed over 300 coding professionals in the US, only 65% of medical
records contained a physician’s discharge note at the time of coding. The discharge summary,
which provides historical information, describes the chief complaint and summarises the course of
treatment, final diagnoses and procedures, and is a vital tool in assisting the coder, was only found
in 20% of records of discharged patients at the time of coding. The operative report was found in
50% of records at the time of coding. Since this study, dictated reports and some electronic health
record applications and other online reports are now available for viewing by coders. However,
most coders still agree that incomplete medical records remain an impediment to the coding
process. The emphasis on quick turn-around for billing (48-72 hours) still leaves coders with
incomplete medical record documentation on which to base accurate and complete code
In all four countries, documentation issues were the primary concern for coding quality. This is
despite years of discussions and active promotion by Health Information Managers of the necessity
for high quality documentation on which to base abstracting and coding.
Around two-thirds of Australian coders stated that they regularly undertook quality assurance
activities to assess the quality of coding output. Over 60% of Canadian respondents reported that
they participated in staff meetings to discuss data quality issues ‘irregularly or never’, and over half
of the respondents indicated that they never perform coding audits. In the US, healthcare
organizations conduct routine coding compliance audits performed internally by supervisory coding
staff in most hospitals, with quarterly or bi-annual coding compliance audits conducted through
external contracts with compliance audit firms, as a safety check against potential fraud and abuse
charges. In general, coding accuracy rates across all hospitals for inpatient, outpatient and
Emergency Department coding are considered appropriate when within the range of 95-100%
accuracy on periodic sampling reviews.
Resources and Support for Coders
Because of the variety of uses for coded data noted earlier, there has been increasing emphasis over
recent years in the provision of resources and support for clinical coders to assist them with
producing high quality coded data.
Access to Resources
The three organisations involved in the Australian coder survey – the National Centre for
Classification in Health, the Health Information Management Association of Australia and the
Clinical Coders’ Society of Australia - each provide support to the clinical coder profession. The
NCCH is an Australian expert centre in health classification theory and coding systems. Funded
primarily by the Commonwealth Department of Health and Ageing, the Australian Institute of
Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS), the NCCH maintains
the ICD-10-AM (which comprises the Australian modification of the ICD-10 for diseases, plus the
Australian Classification of Health Interventions and the Australian Coding Standards), provides
support to the ABS and the AIHW in their use of the ICD-10 and ICD-10-AM for national data
collections, supplies continuing education for Australian coders, develops products for supporting
the work of coders and for assessment of coding quality, conducts research and has an active
consultancy service for national and international clients. The HIMAA is Australia's peak body
representing the interests of the health information management profession. In addition to
promoting and supporting the profession, the Association delivers distance education programs in
coding and related subjects. These programs are principally aimed at entry-level coders, although
intermediate and advanced courses are also available. The CCSA is an organisation originally
established by the HIMAA to represent the clinical coder profession. The establishment of the
CCSA was one of the major outcomes of the first Australian National Coder Workforce Issues
Project in the mid-1990s. The Association is also active in the provision of coder training, mainly
through short courses and workshops. It also provides a support network for coders.
Australian coders identified all of the resources to which they have access in order to help them
code. Most Australian coders had access to a full set of current edition coding books (94%) and to
the NCCH publication Coding Matters (89%), while around half of all coders had access to the
Code-L coding query/support list server (40%) or an encoder (42%). Interestingly, over half of all
coders had access to a computer and the Internet, email, and Code-L, with less than 5% of coders
not having access to any of these resources. Nearly three-quarters of Australian coders indicated
that they had access to clinical staff, with one-third of these coders indicated that they accessed
clinical staff via adhoc meetings with clinicians to discuss specific coding issues.
In England, the National Clinical Classifications Service of the National Health Service Information
Authority, support the clinical coder workforce through the development and maintenance of
clinical coding and auditing standards, training and development of support materials.
Most English coders had access to ICD-10 volumes 1 and 3 (99.6%), while only 30% of coders had
access to an encoder. Coders reported whether they had access the email or the Internet, with less
than three-quarters of coders having access to either of these resources. Nearly one-third of English
coders indicated that they did not have access to clinical staff with whom to discuss coding
US coders regularly use commercial encoder and grouper software to assign codes and group for
reimbursement under DRGs and APCs. Encoders are equipped with all current ICD-9-CM and
CPT-4 codes, coding guidelines and rules governing reimbursement requirements. The American
Health Information Management Association has several internet-based ‘Communities of Practice’
for regular member/coder communications, chat rooms and discussion groups. In addition, state and
regional 'Coding Roundtables' serve as meetings to discuss and share ideas for coding problem-
solving. The AHIMA provides numerous resources for coders, including an audio seminar series
Coders in Australia appear to have similar access to coding resources such as coding books,
encoders and technology as coders in England and America. However, more Australian coders had
access to clinical staff than English coders, with nearly 75% of Australian coders having access to
clinical staff compared to two-thirds of coders in England. Both Australian and English coders
accessed clinical staff largely through adhoc meetings. Data was not available for America or
Canada on access to clinical staff.
Over 90% of Australian coders stated that their facilities supported their participation in continuing
education events, with the most common type of continuing education event accessed being the
update workshops offered by the NCCH prior to the implementation of new editions of ICD-10-AM
(65%), followed by NCCH print based materials (47%), and Health Department coding meetings
Nearly 80% of English coders stated that their facilities supported their participation in continuing
education events, with the most common type of continuing education event accessed being onsite
coder training (20%), followed by other workshops (19%) and other external training (17%).
Only 38% of Canadian survey respondents reported having a professional development budget. The
major types of education sessions attended in rank order were ICD-10-CA/CCI training (67%), in-
house education (43%), CIHI events (30%), CHIMA tele-workshops (18%), and the annual
CHIMA conference (13%).
In America, coder training is offered through the AHIMA 'approved coding programs', AHIMA's
‘Coding Basics’ entry-level training program and the ‘Computer-Assisted Training System –
CATS’ for advanced, web-based training. Continuing education audio seminars, textbooks, and
other offerings are also available through AHIMA. Many of AHIMA's accredited colleges and
universities offer local coding continuing education programs. Commercially, companies market
web-based training products and coding seminars.
Respondents to the Australian, English and Canadian surveys were asked about the type of
continuing education sessions that they would find most useful. Australian coders indicated that
specific coding topics such as diabetes, procedures, obstetrics, orthopaedics and neoplasms/cancer
would be most useful as these were seen as areas of difficulty for coders. English coders were
interested in continuing education on details of anatomy, physiology, medical terminology, and new
procedures, along with specific coding topics such as obstetrics, orthopaedics and neoplasms.
Canadian respondents indicated that they would be most interested in specific body system coding
topics and data quality topics, and many survey respondents also indicated an interest in education
for computer skills development, and stress and time management.
Some of the key findings to be identified in this paper include:
More of a focus on the task of coding in England and the US than in Australia, with
Australian coders more likely to be involved in other activities besides clinical coding.
Higher percentage of coders with tertiary qualifications in America and a lower percentage in
Nearly twice as many coders had no formal education beyond high school in America
compared to Australia.
American coders earn 30% more than coders in Australia and Canada, and twice as much as
English coders; Australian and Canadian coders earn 30% more than English coders.
Higher credentials and/or more experience associated with a higher salary in all four
The overall number of coding vacancies was similar in Australia, England, and Canada with
around 40 current vacancies in each country, while America appeared to have more vacancies
with over 90% of coders indicated there were vacancies in their regions.
Coding throughput requirements were highest in England with over 80% of coders having
targets to meet, compared to 44% of Australian coders and less than 20% of Canadians.
Looking at the number of records to be coded per day, the American coders have the lowest
reported throughput targets. This may reflect the different roles of coders with Australian
coders having considerably more tasks to do besides coding than coders in other countries. It
may also reflect the focus on complete and accurate coding for countries where coded data is
used as the basis for reimbursement.
Documentation issues were of primary concern for coding quality in all four countries.
However, there was more emphasis on coders conducting quality audits in Australia than in
the England or Canada and a significant emphasis on coding quality in the US because of the
coding compliance requirements for reimbursement purposes.
Coders had similar access to resources between Australia and England, though slightly more
coders had access to clinical staff in Australia than England
There was generally good support for continuing education activities across countries, with
coders indicating topics of interest ranging from specific coding and clinical topics to
technological skills and management skills
Despite the reported similarities and differences in the coder workforces discussed in this paper, it is
important to note that the data may have been affected by the varied response rates and different
workplaces of coders across the four countries. Response rates varied from around 20% to over
50% and respondents indicated that they worked in a variety of workplaces, differing across
countries. This may have influenced some of the results and account for some of the variability
Overall though, this paper has described the findings of the national surveys of clinical coders
conducted in Australia, America, England and Canada in recent years and has identified the
similarities and differences in important aspects of the coder workforce at an international level.
Biography of Main Presenter
Sue Walker BAppSc (MRA), GradDip(Public Health), MHlthSc
Sue Walker is Associate Director of the National Centre for Classification in Health. As such, she is
responsible for the management of staff and activities at the Brisbane site, located at the Queensland
University of Technology. Under her guidance, NCCH research and development staff have
developed a close network of contacts with health data coders, researchers and users with whom
collaborative projects have been conducted relating to ICD-10 and ICD-10-AM codes and
standards. Sue has maintained an active publication record producing over 20 papers for journals,
conferences and international meetings, two monographs and a book chapter in the last five years.
Sue has qualifications in health information management, public health and health services
management and has worked in public and private sector hospitals, health departments, data
registries and universities. She has extensive experience in developing and presenting training
programs about health classifications for both international and Australian audiences. Sue has been
elected to various executive positions in both national and state branches of the Health Information
Management Association of Australia, culminating in her election as national President of the
Health Information Management Association of Australia in 1993-5. In 1999, Sue was awarded a
HIMAA Appreciation Award for services to the profession. Sue is a member of the Health
Information Management Association of Australia, the International Federation of Health Records
Organisations, the Public Health Association of Australia and the Australian College of Health
Service Executives. Sue is a past member of the Executive Committee of the International
Federation of Health Records Organizations.
The NCCH has a collaborative arrangement with the Australian World Health Organization
Collaborating Centre for the Family of International Classifications, located at the Australian
Institute of Health and Welfare. Sue contributes to the work of WHO through mortality, morbidity
and disability coding networks and committees and global training and credentialing activities. She
has been invited to conduct numerous consultancies regarding health classification and health
information management for WHO, AusAID and other philanthropic donors.
Biographies of Other Session Presenters
Claire Dixon-Lee PhD, RHIA, FAHIMA
Claire Dixon-Lee is Vice President for Accreditation and Education at the American Health
Information Management Association, Chicago, Illinois. She is responsible for college and
university relations, strategic direction of health informatics and information management academic
curricula, and maintenance of policies and procedures for national and international programmatic
Previously, Dr. Dixon-Lee was president of MC STRATEGIES, INC., Atlanta, Georgia, a coding
and financial management consulting and web-based training services firm as well as having
worked for several well-known clinical data applications companies.
She was an Alexander M. Schmidt Fellow at the University Healthsystems Consortium in
Oakbrook, Illinois, and has over 30 years of academic experience in health information
management education, most recently at the University of Illinois at Chicago, where she is still an
adjunct professor in the School of Public Health – Public Health Informatics.
Dr. Dixon-Lee is a past president of AHIMA and former chair of the Joint Healthcare Information Download full-text
Technology Alliance (JHITA). She holds a master’s degree in Epidemiology from SUNY at
Buffalo, and a doctoral degree in Public Health Policy and Administration from the University of
Illinois at Chicago.
Judith Moran Fuke
Judy Moran Fuke is an information management specialist with many years of progressive
responsibilities in the health care industry. She currently holds the position of Manager, Education
and Professional Practice for the Canadian Health Information Management Association.
Judy’s previous work experience includes Director, Health Records for the Royal Victoria Hospital
in Barrie; Director, Health Resources Unit for the Ontario Hospital Association; Director,
Admitting and Health Records for the Women’s College Hospital in Toronto and Coordinator,
Health Records at Hospital Computing Services of Ontario. In addition, Judy has significant
experience as a health records consultant, working for various health, computer and management
Judy is a certificant of the Canadian College of Health Record Administration and is currently
studying in the Administrative Studies Program at the York University in Ontario. Her work for the
health information management profession in Canada was recognised by her peers through
awarding of a Tribute to Excellence Award by the Canadian Health Record Association. Judy is a
member of the Canadian Health Information Management Association and the Canadian
Organization for the Advancement of Computers in Health. She is a former President of this latter
organization and is also a Past President of the Ontario Health Record Association.
Gareth works for the National Health Service Information Authority in the United Kingdom as part
of the Clinical Classifications team.
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salary”. Journal of the American Health Information Management Association, 74, 7 (2003): 20-27.
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9 Available at www.qstat.cihi.ca.
10Available at http://siteresources.worldbank.org/ICPINT/Resources/Table5_7.pdf
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A Thriving Workforce. Chicago: American Hospital Association, 2002.
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