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شمان مجلس الضمان الصحي Council of Health Insurance CLINICAL CODING AUDIT ROADMAP September, 2025 [Non-Text] CLINICAL CODING AUDIT ROADMAP CLINICAL CODING AUDIT OVERVIEW Definition: A clinical coding audit is a validation process to review the reported clinical coded data (claim) against the clinical documentation generated by physicians and other clinical documentation within the care delivery process. Benefits: • Identifying errors and discrepancies - Improving specificity and completeness of clinical documentation • Ensuring compliance with coding standards and regulatory guidelines • Providing education to coders - Improving revenue cycle management (better cash flow, fewer denials) Regulator Accreditation Road Map شمان مجلس الفصلان الصحي Council of Health Insurance 2 [Non-Text] Step 1: Establish Governance Framework Governance Framework: Rules governing the audit process including planning, accreditation, appeal, arbitration, compliance, communication etc. can be found in CHI “Clinical Coding Audit Governance Document” - Develop the audit governance including regulations requiring healthcare providers to undergo regular clinical coding audit along with penalties and corrective action in case of non-compliance. - Define auditors' competencies and third-party auditing companies' eligibility. Step 2: Develop Audit Methodology - Define coding classifications and guidelines/standards - Define any additional requirements for providers in terms of accuracy and completeness - Define types and frequency of audits - Define the criteria for selecting audit samples - Provide example of common coding errors - Provide scoring method - Develop tools, check lists and standardized forms/templates Note: The complete methodology of the audit and the steps of the audit process is covered in detail in the CHI “Clinical Coding Audit Methodology Framework Document”. مجلس الفضمان المحيي Council of Health Insurance [Non-Text] 3 [Non-Text] Step 3: Establish Clinical Coding and Auditing Committee Regular meetings, clear responsibilities, and ongoing education for stakeholders and committee members is essential for maintaining a high-functioning audit committee. As healthcare organizations face increasing pressure for better performance and accountability, the formation of a robust auditing governance committee is not just advisable but necessary for ensuring long-term financial health and maintaining public trust. The following attributes are essential to the formation of an internal and external auditing framework. - Audit planning - Accreditation - Appeals - Arbitration - Coding accuracy - Compliance - Communication - Selection criteria • Documentation review The stakeholders committee will have the following duties: 1. Determine stakeholders for internal and external audits 2. Continuous assessment of internal and external audit methodology 3. Structure, process, and outcome improvements across the health sector. 4. Improve quality of medical coding and clinical documentation. 5. Focus on the delivery of quality healthcare. 6. Rules and regulations to collaborate with stakeholders and apply fair processes. 7. Disseminate information and knowledge to improve care. شمار مجلس الفضان المحيي Council of Health Insurance [Non-Text] 4 Step 4: Endorse vendors 1. Select the vendors based on the eligibility criteria defined in the audit governance framework 2. Select vendors with sufficient capacity to cover the market accreditation requirements 3. Establish an endorsement process a. Application for vendors seeking endorsement from CHI b. Required attachments (documents, credentials, client references, etc.) c. Interview with CHI Coding Audit Committee 4. Establish an evaluation and approval process a. Define a scoring system to be used by the audit committee to evaluate applications b. Issue certificates officially for endorsed vendors 5. Promote transparency and accountability by maintaining an open public list of all endorsed vendors including a profile of each vendor with detailed information about qualifications, services, and contacts. 6. Conduct ongoing monitoring of the endorsed vendors including submission of performance metrics and periodic reviews 7. Maintain open communication channel with vendors to collect feedback, provide guidance, resources and access to regulatory updates 8. Establish a renewal and revocation process a. Set the timeframe for endorsement validity expiration b. Define steps for the process of renewal c. Define standards leading to nonrenewal in case vendor fails to meet them psom مجلس الفمن المحي Council of Health Insurance 5 Step 5: Conduct Pilots - Implement the audit process on limited number of facilities • Monitor the process and collect feedback - Refine the process, methodology, tools, etc., based on pilot findings External audit workflow psom مجلس الفيمان الصحي Council of Health Insurance [Non-Text] 6 Step 6: Review/Update Standards Review and recommend updates to the CHI Health Information Management Standards in CHI Provider's Accreditation and Classification program that are incorporated into the audit methodology, including HI.4, related to: • Percentage of files reviewed by senior auditors • Coder accuracy threshold • Internal/External audit implementation Step 7: Market Awareness - Develop comprehensive training material that explains in detail the benefits of the audit, the process, the audit types, the score, etc. - Hold workshops to educate the market about the process - Launch a public campaign of information, posts and infographics with a mix of different digital media channels (emails, social media, press releases) to reach broad audience - Engage with professional associations, societies or partners in the market and join in conferences, webinars, and other events - Promote success stories and develop a reward or recognition program to highlight providers that participated in the refinement of the process, or passed multiple years in a row, for example. psom مجلس الفمن المحي Council of Health Insurance [Non-Text] 7 [Non-Text] Step 8: Implement Audit - Release a mandate with relevant dates for the implementation of the audit process • Go Live with audit process Step 9: Analyze and Report Findings • Collect audit report for each audited facility - Analyze the audit result to identify common coding issues and trends in the market that might require education • Use statistical methods to assess overall compliance levels - Summarize findings, highlight strengths, and identify areas for improvement Step 10: Feedback and Update - Collect feedback from both audited facilities and vendors (surveys, groups, etc.) - Communicate audit findings and trends to other stakeholders (public sector, policy makers, etc.) - Develop education programs based on report findings for healthcare providers to improve coding practices - Offer workshops, webinars, and resources on coding standards and best practices - Maintain the audit process • Regularly review audit criteria and guidelines - Update standards based on new regulations, coding changes, and audit findings psom مجلس الظمان الصحي Council of Health Insurance [Non-Text] 8 CLINICAL CODING AUDIT CHI 2025