The Remote Clinical Coding Auditing Model
Crammed into a small office, trawling through poorly filed case notes. Traditionally, clinical coding audits aren’t the most glamourous. But the COVID pandemic and new ways of working have seen some audits go remote.
Can a remote audit still deliver the same experience as a traditional onsite audit?
The clinical coding landscape has changed dramatically over the past 5-10 years with many hospitals converting to EPR systems to either replace or supplement the traditional paper record. With this introduction of EPR, remote working has increased, and the COVID pandemic has only accelerated this.
So how has the COVID pandemic affected the clinical coding audit?
For hospitals without EPR systems, their audits are still carried out the traditional way – on-site with case notes. Auditors just need to comply with local COVID guidelines.
Hospitals with EPR systems are frequently requesting that audits be carried out remotely to avoid unnecessary visitors to site and the difficulties that come with securing a suitable workspace. The practicalities are actually pretty simple, give the auditors the same access as the coders and off they go. It’s also one less stress for the medical records department.
This year’s Auditors forums were also held remotely, and will be for the foreseeable future.
At Monmouth, we have spent the past 2 years adapting our audit process to meet these new requirements and working hard to ensure the experience works for both the hospital and for us as auditors.
For our clients with an EPR system and remote capabilities we send coding queries to the coding lead with detailed explanations and anonymised screen shots for the coding lead to review. This makes the whole process of query review far more streamlined. Post-It notes and tabs are no longer required, and sites can review them in their own time and any evidence to support their coding can be sent back to the auditor.
Daily updates and feedback are given virtually to site and our auditors also have regular meetings to discuss what we’re finding and the patterns we’re identifying.
Sounds perfect, but like we have all experienced since 2020 – virtual meetings are great – though they are not quite the same as a face to face. This is the major drawback of the remote coding audit, a process that has too often been seen as a negative experience by many coders.
Someone is coming to assess their work and spot where they’ve gone wrong – it’s no wonder they don’t look forward to them – and with the auditor sitting miles away behind a screen, an audit can seem quite cold if proper care is not taken.
To combat this, we’ve begun to introduce an onsite date to the end of our remote audit. That way, the advantages of the remote audit remain but the advantages of the face to face meetings you have with a traditional audit is not lost.
This successful model is one we are going to carry on working with in the future as we move into the DSPT coding audit season.
What’s your experience of the remote audit? Let us know your thoughts.