Clinical coding audit reports

The coding audit is finally over, so how do you communicate the audit findings?

At the conclusion of each clinical coding audit, it’s necessary to collate the audit data and coding statistics in a concise and readable coding audit report for coding management and executive teams.

Whether you’re after a detailed clinical coding audit report or just a summary of the audit findings, it’s imperative that the information is conveyed clearly and is relevant to your audience.

A coding audit report should detail the findings from the audit, which have been conveyed at a conclusion or exit meeting. Findings should address initial goals for the coding audit, and the report should include meaningful and specific audit recommendations that can be implemented by the health service.

An extract of the audit details from each episode should accompany the coding audit report, and include rationale for changed codes and financial variances (where applicable).

Keeping consistent audit notes for each episode improves the audit reporting process and improves the understanding for the end users, including clinical coders, executives and managers.

Clinical coding audit report tips:

  • Complete the audit data analysis prior to preparing your clinical coding audit report
  • Use a standard audit report template as a foundation
  • Set the context and provide detail of the audit scope and methodology
  • Answer the ‘so what’ question, and if you can’t, leave out the finding
  • Review, review and review again
  • De-identify coder names if the report is to be disseminated
  • Consider the language used to ensure feedback is embraced and not rejected
  • Only include information that was presented at the on-site conclusion meeting
  • Limit the use of coding jargon.

Our Mamco coding audit reports are easy to read, present content that is relevant to the audience, and provide clear recommendations for ongoing improvement and coder development.

Contact us to discuss how we can assist you in the preparation of clinical coding audit reports or conducting contract coding audits and producing coding audit optimisation samples.