Knowledge is the first step
We understand the critical importance of high quality coded data for the leadership of modern hospital facilities. When analyzed, it informs every decision and is the basis on which resources are determined and allocated.
We ensure that our hospital clients benefit from experienced data quality audit project leadership; cost-effective services tailored to requirements; professional highly trained and certified data quality auditors; experienced consultants and data analysts; and a commitment to meeting expectations and deadlines.
Formal audit process
Since our inception in 2000, Salumatics has evolved an effective, formal process to assess the accuracy and completeness of health record documentation and coding.
In selecting charts, Salumatics employs a targeted sampling methodology to maximize impact on a hospital’s case mix. Typically we review case mix groups (CMG) with high volume and high average resource intensity weight (RIW). A statistically significant number of charts is selected and reviewed for each of these CMGs.
Salumatics has a team of experienced and qualified auditors who will review the charts, and document any discrepancies with the original assigned code. They will also look at the physician’s documentation in light of other elements in the chart, and identify opportunities for documentation improvement, especially those that contribute to complexity or quality measures.
In-depth review identifies opportunities
Following completion of the chart audit and re-abstraction, the audit team reviews the results, and compares these against documented best practices and peer benchmarks. They also identify the potential resource weights to be gained by service and provide recommendations for clinical documentation improvement.
The in-depth review will identify missing, incomplete, unclear or non-specific physician documentation. Our coding professionals will identify opportunities to capture additional specificity, comorbid conditions, complications, procedures and flagged interventions.
Specific, actionable recommendations
Our team shares a commitment to knowledge transfer, and makes specific recommendations with respect to coder education and training, productivity, risk management, departmental organization and quality assurance procedures. Chart management and clinical documentation issues that contribute to coding quality are identified, and changes recommended. Opportunities to increase conformance to CIHI and health ministry standards are also identified which leads to better reflection of resource use and improved performance on key indicators.
Typical additional recommendations are focused on departmental workflow, productivity, training, clinical documentation improvement, and technology enablers.
Reporting and customized training
The final report includes a summary of diagnostic and procedural codes that were missed or incorrectly captured by the original coder. If performed on recent charts, the audit may also result in a significant increase in resource weights for each case mix group – often a critical factor in funding formulas – and coded results can be resubmitted for additional funding.
We provide training material to the coding staff based on our findings, including coding standards to be reviewed and areas to query physicians in order to substantiate lab and radiology results. In addition, our clinical documentation improvement team will provide customized education packages for physicians by program, identifying commonly missed comorbidities and diagnoses lacking specificity.
We have experience working with small to medium-sized rural hospitals and large urban tertiary and academic hospital networks. We will design solutions that fit your needs.
With our team of health information leaders and our experience managing sensitive health information, Salumatics is uniquely positioned to deliver innovative solutions to our clients.