Development of a Coding Audit Methodology Framework for the Private Health Sector in the Kingdom of Saudi Arabia

Susan Young ^a, Wail Yar ^a, Fawaz Alomran ^a, Thilo Koepfer ^b, Anadil Assawi ^c, Michelle Badore ^b

Introduction
As part of Vision 2030's healthcare transformation goals, the private health sector in Saudi Arabia is implementing new and innovative ways toward more transparency in healthcare financing and provision such as National Platform for Health Information Exchange Services (NPHIES), Saudi Billing System (SBS), Minimum Data Set (MDS) and AR-DRGs. Data quality and specifically coding quality are of critical importance for their success. To assess and improve the correct, compliant and accurate assignment of diagnosis and procedure codes the Council of Health Insurance (CHI) has undertaken the development of a Coding Audit Methodology Framework for the private health sector as one important tool among others to measure and improve coding quality in a fair and transparent way.

Methods
Within 12 months the project team developed 1) recommendations for a standardized governance framework for both admitted inpatient and day cases) and non-admitted services (emergency and outpatient services) 2) a comprehensive toolkit defining a complete internal and external audit process for both admitted and non-admitted care services, and 3) pilot tested the newly developed internal and external audit process with six selected private hospitals.

To achieve the project goals the team reviewed the currently existing guidelines and standards in Saudi Arabia and benchmarked coding audit methodologies and their respective governance of other countries such as Australia, the US, Germany and Abu Dhabi (UAE). In addition, several workshops and consultations were conducted with key stakeholders (hospitals, insurances, regulators etc.). After the definition of the initial audit methodology 6 pilot hospitals were identified according to specific selection criteria and subsequently internal and external audits conducted. The findings of the pilot audits and additional stakeholder workshops informed the final Coding Audit Methodology Framework.

Results
CHI was able to develop a comprehensive coding audit methodology framework both for the admitted and non-admitted care services through the above outlined project. The project team showed that it was possible by combining established tools like desktop research, benchmarking and stakeholder workshops to develop a new and comprehensive coding audit methodology framework aligned to the local needs and supporting the fast- evolving private health sector in Saudi Arabia.

Discussion/Conclusions
Complete, consistent, compliant and accurate coding is an important, if not the most important, element for the transformation of the private health sector towards transparent and fair value-based care principals. Internal and external coding audits are a helpful tool, although not the only ones, to continuously improve the coding quality. As such it was critical for CHI to develop and test a standard framework to assure consistency and sustainability of coding audits in the private sector. The pilots with selected hospitals helped to improve the understanding and acceptance of such audits and provided an important baseline for future refinements.


^a Council of Health Insurance, Saudi Arabia
^b Solventum, United States
^c Solventum, United Arab Emirates

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