When an audit process is documented, an organization can prove, whether to the OIG or to hospital administration, that procedures are in place for improving and controlling the quality of coding. Auditing can help to identify sources of coding error. Clerical errors generally represent careless mistakes and are usually random and infrequent. Judgment errors represent subjective, decision-making mistakes. To minimize judgment errors, a coding staff should have proper procedures and adequate training to guide decisions.
Systemic errors are the most important errors.
The OIG identifies them through data trending. Systemic errors can potentially affect every record. How to Audit Hospital Coding Many hospitals have not only automated the coding and abstracting process but have invested in coding audit software as well. In a best-case scenario, automated data is downloaded from the abstracting system into the coding audit software. From a compliance standpoint, it is important that the software provides both of these functions.