Background
Cambridge University Hospitals NHS Foundation Trust has developed an internal audit programme which is closely integrated with clinical coding training and development and improvement in source documentation programmes.
Objective
Real-time audits focus on both coding accuracy and Healthcare Resource Group assignment enabling the trust to understand the implications of errors under PbR.
Outline
For the first two weeks of each quarter, 200 sets of case notes from patients which have been discharged are selected and audited immediately by in house registered auditors. The results of the audits are reported back to the clinical coding manager when completed where coding amendments are made in real time before billing takes place.
Impact
The findings from the audit are shared with clinicians so they can address any issues relating to source documentation. The audits are also used to focus training programmes of clinical coders to address issues as they arise to ensure continuous improvement in the accuracy of coding.
Source: 3M and Cambridge University Hospitals NHS Foundation Trust