Internal Clinical Coding Audit Course

The Internal Clinical Coding Audit Course aims to primarily train the medical coder for the practice of internal clinical coding auditing.

It is a joint initiative of the Administração Central do Sistema de Saúde (ACSS) and the NOVA National School of Public Health (NOVA NSPH), coordinated by both institutions, and qualifies participants to perform internal clinical coding auditing in ICD-10-CM/PCS.

OBJECTIVES

At the end of the course, participants should be able to:

• Recognize the importance of clinical coding and internal auditing of clinical coding within each hospital institution and the health system, in various aspects;
• Understand the auditing process and the related normative framework both theoretically and practically;
• Use techniques to detect and correct non-conformities in clinical coding;
• Utilize tools to support internal clinical coding audits;
• Recognize and apply appropriate behavioral, communicative, and interpersonal skills for internal auditing;
• Understand the role of the medical auditor in ensuring and maintaining the quality of coded information;
• Assume the role of internal auditor in clinical coding, responding accurately and competently to the requirements and expectations involved.

IDEAL STUDENT

The Internal Clinical Coding Audit Course is aimed at those who meet all of the following admission criteria:

• Medical coders with training in ICD-10-CM/PCS who are not currently performing auditing functions;
• Those involved in the clinical coding of ICD-10-CM/PCS episodes of hospital admissions, who, at the time of application, have such data available in the Hospital Morbidity Database;
• A minimum of 12 months of activity;
• For hospitals with an annual total of inpatient episodes of 5,000 or more: at least 1,200 inpatient episodes coded in the last 12 months;
• For hospitals with fewer than 4,999 annual inpatient episodes: at least 800 inpatient episodes coded in the last 12 months.

COORDINATION

Vasco Ricoca Peixoto (NOVA NSPH) | Teresa Matias (ACSS)

COURSE SYLLABUS

• Importance and use of clinical coding and internal auditing;
• Fundamentals of internal auditing;
• Types of auditing in clinical coding and most common errors;
• SIMH Auditing;
• Behavioral components in internal clinical coding auditing.