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. Some programs will allow edits specific to each individual entity to be added. Once the software reviews the daily coded data, cases that have failed the edits are identified.