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1. Clinical Coding AudIT (V2) 2008 Software Presentation This presentation has been modified to reflect AudIT 2008(V2) amendments (September 2008) from one originally prepared by: Sallyanne Wissmann Manager Clinical Coding Services Mater Health Services Brisbane Authors: Sallyanne Wissmann, John O’Halloran, Lucy Fisher a project sponsored by

2. Project Background • PHAQ represents just over 70% of Qld private hospitals • 2004 Health Information Manager Network re-established & has 30 active members • The need for & methodology of clinical coding audits was identified as a high priority for development • In 1997 a clinical coding audit tool was developed by PHAQ • Decided to re-develop the initial 1997 audit tool to meet today’s clinical coding audit requirements a project sponsored by

3. Needs Survey A survey of Qld private hospital HIMs revealed the following: • No standard audit methodology • Audit methodology including sampling tends to be manual • Amount of internal auditing done by hospitals varies • Varied coding audit expertise within sector • Lack of suitable audit tools a project sponsored by

4. Rationale The HIM Network wanted to achieve the following: • Develop a standard clinical coding audit methodology • Develop a tool to facilitate audit sampling, audit data entry, classification of coding errors, analysis and reporting • Provide education and support to Qld private hospital sector (with ability to expand to other users of audit tool) • Benchmark coding audit results between private hospitals • Demonstrate to health funds that coding audits are regularly occurring in the sector a project sponsored by

5. Approach • AudIT2008 (V2)is the coding audit tool that has been developed • Consultative approach with a number of HIMs and Clinical Coders with coding audit experience • AudIT2008(V2)supports coding audit best practice • Since its original development,AudIT2008(V2)has been refined to reflect user feedback with the addition of an expanded suite of management reports and inclusion of HCP file format changes. • AudIT2008 (V2) was released in January 2009 a project sponsored by

6. Creating a Workflow a project sponsored by

7. Import Data Extracts An HCP file format is the initial data extract forAudIT 2008 HCP Plus allows users to quickly import and use additional hospital-specific information: Doctor · Specialty · Ward · Coder a project sponsored by

8. Selecting Audit Type a project sponsored by

9. Selecting AudIT Criteria At the heart ofAudIT2008is a random selection engine for discharge selection Additional filters can be applied to alter the profile of recordsselected a project sponsored by

10. Additional Filters Selection can be filtered by Length of Stay All filters under the heading “Exclusions” will filter out of the selection any criteria which are entered here. Individual DRG’s can be excluded by entering a list of DRG codes separated by commas DRG’s can also be excluded by DRG range. Clicking the “<< Less” button will close the additional filters panel and remove all additional filters. a project sponsored by

11. Performing the AudIT a project sponsored by

12. Performing the AudIT a project sponsored by

13. Performing the AudIT The main “Perform theAudIT” Screen nowshows ared boxnext to any altered codes. Each Discrepancy Reason and Cause can be reviewed again by clicking thered box. a project sponsored by

14. Performing the AudIT a project sponsored by

15. Continuing Australian Coding Standards • Re-establishing a data standard for external morbidity coding errors in theAudIT2008User Network. • Error Statistics derived from agreed definitions.

16. Grouping the Results • AudIT2008 (V2) has an interface with the following 3M Products: Core Grouper Software, Codefinder and COM-DLL. Viewing of the pre and postAudIT2008DRGs is done on the previous screens • Grouping withinAudIT2008 enables reports to be based on DRG changes a project sponsored by

17. Grouping the Results a project sponsored by

18. Grouping the Results Once the Grouping Process is complete, the results of grouping the Records in each workflow is summarised for the auditor. a project sponsored by

19. Generating Reports

20. Analysis and Reporting a project sponsored by

21. Analysis and Reporting a project sponsored by

22. Analysis and Reporting a project sponsored by

23. Analysis and Reporting a project sponsored by

24. Maintenance Functions a project sponsored by

25. Advantages • Easy to use • Designed by HIMs and Clinical Coders • Easy sampling, data entry and reporting • Easy to manage and compare results over time • Suited to multi-campus auditing • Able to have multiple unfinished audits at one time • Flexible with scope for further enhancements • Benchmarking capability • Reasonably priced, cost-effective a project sponsored by

26. Affordable Pricing • $790 per site < 150 beds • $990 per site > 150 beds • Discount for State or Group purchases by negotiation • No charge to PHAQ members a project sponsored by

27. For more information contact: Lucy Fisher Executive Director PHAQ (07) 3279 7600 lucyf@phaq.org a project sponsored by