Auditing in Health Information Management: Documentation, Coding and Clinical Audits

Introduction

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The accuracy of clinical coding is vitally important for all groups who use the resulting databases for the purposes of health services research, allocation of funding, evaluation of health services and clinical interventions, and health services planning. A variety of quality improvement techniques are used to assess the accuracy of clinical morbidity coding, and to introduce changes such as coder and clinician education, clinical documentation integrity, software edits, and coding standards, all of which aim to address issues identified in the accuracy assessment process.

Audits are performed by various organizations including health authorities and other funders/payers (such as Ministry of Health, CBAHI, PHAP, insurance companies), research groups, individual health services, and other agencies with a vested interest in coded data quality (such as the National Health Information Center NHIC, and the Case-mix Center of Excellence CCoE). These audits include statistical analysis of morbidity databases, using Performance Indicators for Coding and Documentation Quality, to identify compliance with coding standards, and medical record recoding audits which also assess code selection and sequencing based on medical record content.

Objectives

By the end of the course, learners will be able to:
- Discuss Compliance, Law and Ethics in healthcare
- Describe Fraud in Healthcare and why audit
- Describe Clinical Documentation Audit, Clinical Coding Audit and Clinical Audits and how they differ
- Recognize the purpose of internal and external audits
- Recognize the characteristics of a good auditor
- Identify the steps and goals of a clinical coding audit
- Discuss audit tools and audit reporting in clinical coding

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