EPA Standard
Clinical Coder
Level 3 £5,000 18 months
1. What the role entails
Clinical coding is the process of translating medical information from patient records in hospitals, into alphanumeric codes. A Clinical Coder will spend time reading medical notes/records and analysing the contents which they then translate into alphanumeric codes that accurately represent the patient’s stay. Clinical Coders locate missing information by whatever process necessary including contacting Medical Secretaries or by pulling case notes and requesting diagnoses from clinical staff where appropriate. They input Clinical Codes onto the Patient Administration Systems, action outstanding clinical coding reports as required, as well as dealing with any queries and taking messages for the staff within the Clinical Coding Department.
The responsibilities and duties of the role are to abstract, analyse and translate medical terminology as written by the clinician, and assign classification codes. These codes are obtained from the International Statistical Classification of Diseases (ICD) and related health problems for diagnoses and/or Office of Population, Censuses and Surveys of Surgical Operations, Interventions and Procedures (OPCS). They apply codes in accordance with National and International Coding Standards and guidelines, following complex rules and conventions of the diagnosis and procedure classification frameworks.
2. On-programme assessment
Apprentices will typically spend 18 months on-programme before Gateway. Whilst on-programme apprentices must:
- train to develop the occupational standard’s knowledge, skills and behaviours (KSBs)
- train towards Level 2 Functional Skills English and maths if not already exempt
- compile a Portfolio of Evidence.
3. Gateway requirements
The end-point assessment (EPA) period should only start once the employer is satisfied that the apprentice is consistently working at or above the level set out in the occupational standard. In making this decision, the employer may take advice from the apprentice’s Independent Training Provider (ITP), but the decision must be made solely by the employer. The following evidence must be submitted at Gateway:
- Level 2 Functional Skills English and maths (or equivalent) certificates
- a Portfolio of Evidence to underpin the Professional Discussion.
4. End-point assessment
The EPA for Clinical Coder contains two methods of assessment:
Clinical Coding Test
The Clinical Coding Test will consist of 2 papers and will be carried out in a controlled environment. Paper A will be an online Multiple Choice Question (MCQ) Test, which will be closed book and take 45 minutes. There will be a total of 20 questions each with four options, of which one correct answer will need to be selected by the apprentice. The multiple-choice questions will cover:
- ten questions on clinical coding skills
- six questions on communication and information governance
- two questions on extraction and evaluation of data
- two questions on IT.
Paper B will be a Clinical Coding Case Study Test. The Clinical Coding Case Study Test demonstrates that the candidate has the ability to use the professional tools needed to apply their knowledge. They will be required to read and review the case study and assign the correct codes using two specified texts. There will be three case studies, each with 20 marks allocated.
The apprentice will complete Paper A before progressing to Paper B.
| Paper A MCQ Test | Paper B (Case Study Test) | Overall Clinical Coding Test Grade |
| Pass | Pass | Pass |
| Pass | Distinction | Distinction |
| Distinction | Pass | Pass |
| Distinction | Distinction | Distinction |
The Observation of Practice lasts for a minimum of 90 minutes, and takes place during the apprentice’s work day. It’s essential for assessing skills. During the Observation, an Independent End-Point Assessor (IEPA) will use their professional judgement to limit impact to business operations and will ensure sensitivity in delicate situations.
Professional Discussion
The apprentice will complete a structured discussion with the Independent End-Point Assessor (IEPA), to demonstrate the KSBs associated with this assessment method. During the on-programme phase of the apprenticeship, the apprentice will compile a Portfolio of Evidence to evidence the KSBs. The Portfolio of Evidence will not be assessed, but will inform the questioning in the Professional Discussion. During the Professional Discussion, the IEPA will ask a minimum of five questions, to explore the apprentice’s knowledge and experience.
The Professional Discussion will last 60 minutes (+10% at the discretion of the IEPA).
Grading: the Professional Discussion is graded Fail, Pass or Distinction.
5. Grade aggregation table
| Clinical Coding Test | Professional Discussion | Overall Grade |
| Pass | Pass | Pass |
| Pass | Distinction | Pass |
| Distinction | Pass | Pass |
| Distinction | Distinction | Distinction |
If an apprentice fails any assessment method, the entire EPA will be deemed an overall Fail.
6. Completion and certification
We’ll activate certification once the apprentice has successfully completed all EPAs, and the IEPA has verified this. Working with the apprenticeship certificate issuing authority, we’ll ensure the apprentice receives their certificate.
7. What next?
Completion of the Clinical Coder apprenticeship may provide progression opportunities to more senior positions such as Senior Clinical Coder, Clinical Coding Team Leader, Clinical Coding Supervisor, Clinical Coding Trainer, Clinical Coding Auditor, Clinical Coding Assistant Manager, or Clinical Coding Manager. It may also be possible to advance to higher level healthcare.
Why NCFE?
We’re an approved End-Point Assessment Organisation (EPAO) specialising in EPA delivery across health, education, early years, digital, social care, finance and business apprenticeship standards. We offer flexible and reliable EPA solutions supported by sector expertise, guidance documents and proactive service and support.