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JAWDA DATA CERTIFICATION (JDC)
CERTIFICATION RULES
FOR HEALTHCARE PROVIDERS
Methodology 2019-Part II
(ANNEXURE & APPENDICES)
December 18
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COPYRIGHT PROTECTED DOCUMENT
© DoH 2019, Published in United Arab Emirates
All rights reserved. Unless otherwise specified, no part of this publication may be reproduced or utilized otherwise in
any form or by any means, electronic or mechanical, including photocopying, or posting on the internet or an intranet,
without prior written permission. Permission can be requested from either DoH /TASNEEF at the address below.
DoH Address:
Tel.
Fax.
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1 GENERAL .................................................................................................................................................................................................. 6
2 APPLICATION AND PLANNING FOR CERTIFICATION ................................................................................................................................. 7
2.1 Contract formation ........................................................................................................................................................ 7
2.2 Audit Planning ................................................................................................................................................................ 8
2.3 Audit Sample Type for Claims Review ........................................................................................................................... 9
2.4 Sampling method For Claims Review .......................................................................................................................... 10
2.5 Sampling for KPI Process and Validation: .................................................................................................................... 10
2.6 Random Sample Sharing for Claims Review: ............................................................................................................... 10
3 PERFORMANCE OF AUDITS .................................................................................................................................................................... 11
3.1 General ......................................................................................................................................................................... 11
3.2 Audit Process: .............................................................................................................................................................. 11
3.3 Audit Evidence Collection ............................................................................................................................................ 12
4 CERTIFICATION REQUIREMENTS AND GUIDELINES FOR CRITERIA ......................................................................................................... 12
4.1 JAWDA Data Certification ............................................................................................................................................ 12
4.2 Claims Review .............................................................................................................................................................. 13
4.3 Clinical Coding Process Review .................................................................................................................................... 16
4.4 Process Review for: “KPI” Quality Indicators ............................................................................................................... 18
4.5 KPI Validation for Collection and Submission of Jawda Quality Indicators ................................................................. 21
5 DENTAL SERVICES ................................................................................................................................................................................... 22
5.1 Audit Verification Points: ............................................................................................................................................. 22
6 AUDIT ON SELF-PAY SERVICES/PROFORMA SERVICES ........................................................................................................................... 23
6.1 Audit Verification Points: ............................................................................................................................................. 23
7 REPORT ................................................................................................................................................................................................... 24
7.1 Audit Report Format .................................................................................................................................................... 25
8 NON-CONFORMITIES AND CORRECTIVE ACTIONS ................................................................................................................................. 26
9 WEIGHTS AND SCORING ........................................................................................................................................................................ 27
10 DECISION MAKING ................................................................................................................................................................................. 27
10.1 Passing Grade system for JAWDA Data Certification................................................................................................... 28
11 RE-AUDITS .............................................................................................................................................................................................. 28
12 LISTING AND DE-LISTING ........................................................................................................................................................................ 29
12.1 Impact of De-listing (Gap in Listing) ............................................................................................................................. 30
13 TRANSITION PHASE OF OLD TO NEW METHODOLOGY: ......................................................................................................................... 30
14 MAINTAINING VALIDITY OF THE CERTIFICATE ....................................................................................................................................... 30
TABLE OF CONTENTS
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14.1 Management of Certificates ...................................................................... 31
15 MODIFICATION OF CERTIFICATION AND COMMUNICATION OF CHANGES ........................................................................................... 31
16 CONDITIONS AT WHICH AUDIT PROCESS WILL STOP ............................................................................................................................. 31
17 CONDITIONS AT WHICH CERTIFICATION PROCESS MAY BE SUSPENDED .............................................................................................. 32
18 SUSPENSION, REINSTATEMENT AND WITHDRAWAL OF CERTIFICATION .............................................................................................. 32
19 RENUNCIATION OF CERTIFICATION ....................................................................................................................................................... 33
20 NEW FACILITY LISTING AND EXTENSION OF LISTING ............................................................................................................................. 33
21 COMPLAINTS MANAGEMENT ................................................................................................................................................................ 34
APPENDIX .......................................................................................................................................................................................................... 1
APPENDIX-I ....................................................................................................................................................................................................... 2
APPENDIX-II ...................................................................................................................................................................................................... 5
APPENDIX-III ................................................................................................................................................................................................... 10
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ANNEXURE
CERTIFICATION RULES
for
JAWDA Data Certification for Healthcare Providers -
Methodology 2019 Part -II
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1 GENERAL
These rules constitute integrate the Contract between certification body (TASNEEF) and Healthcare Facilities. These
Rules are an integral part of the Methodology to achieve the JAWDA Data Certification. In this perspective, the rules
describe to identify criteria that Facilities can or must apply for the JAWDA Data Certification related to the DoH JDC
Methodology 2019 and how facilities can apply for obtain, retain, renew and use this certification, as well as its
possible suspension and revocation.
1.1. Certification is in accordance with DoH JDC Methodology (dated January 2019) to facilities where Management
System must be recognised as conforming. The Criteria of the certification are represented from the Methodology
and other requirements of the reference standards or guidelines described in this document.
1.2. Certification is open to all Healthcare facilities in Abu Dhabi belonging to the following categories and encounters:
• Hospitals
• Medical Centres, Clinics, Home care Centers, Telemedicine, Long Term Care Centers /Rehabilitation Centers
facilities/Dental Centers and all facilities offering Self-Pay Services Excluding Pharmacies, Optical shops, School
Clinics and exclusive diagnostic laboratories, Dental Laboratories, Orthotics and Prosthetics.
TASNEEF is entitled to refuse requests for certification by facilities whose activities have been subject to restriction,
suspension or proscription by a public authority.
When TASNEEF declines an application, the reasons shall be communicated to DoH and the facility CFO/CEO/COO or
delegated authority including the representative for audit.
1.3. This document provides also guideline to the Criteria applicable to the certification process because the JAWDA Data
Certification is oriented to apply a complete third-party concept audit.
Quality means the ability to satisfy requirements of regulatory, moral, material, social and economic nature,
translated into stated requirements.
The quality of the health service (intended as the ability to satisfy the associated needs) is the result of a:
• series of scientific, technical and technological, organizational, procedural, relational and communicational
elements in which a determining role is carried on by the human variables (health operators and service
customers – in this concept is patients) that strongly interact in the realization processes, even more than in
other activities also essentially based on human relations, such as education
The elements to be considered in quality in health and associated achievement services are therefore numerous and
complex for example through:
1.4. adequate organization of the structure and suitable management of the primary and supporting services, which are
reflected, though not strictly, in the ISO 9000 and other international standards and accreditation systems;
• adequate definition of the "technical" content of the services provided (service specifications), which
corresponds to a series of specialized standard references of which medical-scientific documentation and
diagnostic-therapeutic protocols are particularly important;
• qualification of assigned personnel (basic training, applicative knowledge, human skills and ethics behavior),
which is related to the mechanisms of recruitment, selection, training;
• medical-scientific reference documentation (Protocols, Procedures or Instructions, etc.) that are used to support
the records.
1.5. The JAWDA Data Certificate issued pertains exclusively to a single healthcare facility identified by its HAAD (DoH)
license number.
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2 APPLICATION AND PLANNING FOR
CERTIFICATION
Facilities wishing to obtain certification for their JAWDA must provide TASNEEF with their main facility data and site
location by filling in all parts of the “APPLICATION FORM” on TASNEEF website at www.tasneefba.ae/jdc to initiate
the Certification process
Facilities applying for the first time, apply for certification thru the online application and notifications are received in
the [email protected] e-mail.
• Name of the Facility
• DoH License No.
• Facility Settings
• Contact Details
• Other mandatory fields
This information should be provided by an authorized representative of the applicant organization and shall be the
point of contact for the entire certification process.
• For the re-certification, apply thru downloading the registration form online and are sent the [email protected]
e-mail and /or to admins. Facility must confirm the schedule and share the facility location and contact details
along with location map and landmark.
• All the requests should accompany with the copy of DoH license.
• All correspondence will be sent to the registered emails only, and changes must be notified to TRBA
2.1 Contract formation
i. TASNEEF will open file with the provided information and a contract with fixed prices approved by DoH will
be sent to the provider per the type of facility and applicable tier system based on volume of claims
submission, which is provided by DoH, and then contract will be sent to the authorized representative for
certification. The Pricing Tariff list is published on TRBA webpage.
ii. Details of Tier information is as provided in Appendix-I Tables of Tier system
iii. All the Licensed facilities with Facility type as Provision of Health Services, are applicable for contract category
as (Tier HC) Home Healthcare. Facilities with license subtype as Medical Center but authorized as Homecare
service provider additionally are also applicable for Tier HC contract.
iv. All the facilities with Facility Type as Rehabilitation center are applicable for Contract Category-Medical Center
(Tier-M) provided they do not have Home health and long-term care services.
v. Facilities with License of facility subtype as Rehabilitation Hospital shall be applicable for contract as Tier-RH.
vi. If a facility has a mix of settings, the facility will be considered with the contract of higher setting as per JDC
tariff. Example, if a facility has settings as outpatient, and homecare, the contract shall be considered for
homecare. If a facility has outpatient, day case and homecare, contract shall be of homecare.
vii. If a facility has outpatient and inpatient claims, the contract shall be issued as a Center, however, there will
be additional charges to cover the cost of additional man days required for the audit of Inpatient claims.
viii. For Self-Pay, Tier system is applicable only if submission is done for a minimum of 6 months, otherwise
contract with flat rate for Self-Pay will be applicable. This is to promote as an incentive for continuous
submission compliance for Self-Pay activities.
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ix. The audit process for proforma payers (services which are not paid
either by patient or insurance companies) is same as the self-pay audit process. Self-pay tier system and prices
are applicable for Proforma services as well. For the purpose of this certification, Self-Pay and Proforma are
considered to follow same audit process.
x. In addition to Tier system, centers with applicability to KPI submissions will be charged additionally to cover
the man days,
xi. As per DoH, Ad-Hoc KPI is mandatory to be conducted at least once per year, hence a contract for ad-hoc KPI
will be shared in addition to the contract of regular (annual) JDC audit, and the ad-hoc audit will be conducted
at a later point of time.
Acceptance of the contract is made by sending TASNEEF the specific form signed and attached to the contract and any
other document per which certification is requested.
On receipt of the signed contract for certification and the relative annexes as applicable and having ensured they are
complete, TASNEEF will send the facility written acceptance of its application and will proceed to generate the invoice
along with other additional steps for the audit process.
The agreement signed between TASNEEF and the facility includes:
1) Certification fee
2) Information on fee for Follow-up Audits if applicable to the facility as mentioned in the contract and as per
the applicable General terms and Conditions
3) A single consolidated package price applicable as per the Tariff published on TRBA website. The tariff selection
is done based on the Tier of General claims and applicability of dental and Self-pay services in scope.
4) Facilities which are exclusive dental centers without general medical services will follow the tier system of
Dental and tariff accordingly.
5) Self-Pay tier system and Tariff are applicable to facilities only with exclusive self-pay services.
6) Facilities with only Dental and or Self Pay will be applicable for contracts related to specific services
7) After the satisfactory completion of the initial audit and after validation by TASNEEF, a Certificate of
Conformity with the reference standard, if meets the criteria, will be issued.
8) Contract information for Re-audits as applicable per methodology
2.2 Audit Planning
i. The application for certification should be initiated by the facility at least two months prior to the schedule of
audit date of listing expiry published on Shafafiya.
ii. The facility is required to share the list of Coders with their certification and other department personnel
details in the scope of audit process and interviews at least 3 weeks prior to the audit schedule.
iii. If facility management changes, but still bears the same DoH License Number, the facility will still proceed
with the JDC audit with claim samples to be taken from the previous 12-13 months and not from the date of
management change.
iv. Any request for re-schedule should be sent at least 1-2 months before with documented reason for request.
In the absence of relevant documentation supporting the reason, the schedule will not change, and the audit
will proceed with actual schedule.
v. Only one reschedule request can be accommodated for any emergency reasons with supporting
documentation and the new schedule can be provided as per the availability of audit slot.
vi. Schedules for KPI audit will be as per the claims schedule, however, if is delayed for specific reasons, will be
communicated by TRBA with earliest possible schedule without causing any listing impacts due to delay.
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vii. Any request for re-schedule with-in one month from scheduled date
will incur additional charges.
viii. The assigned schedule may be canceled if application is not received in not less than 2 weeks prior to given
schedule.
ix. An audit plan will be communicated to the facility within a week before the audit schedule.
x. In case of delay in application by facilities, the above timeline may be affected, and the audit plan shall be sent
only after receiving the required information.
xi. Facilities with electronic medical records should keep ready and send to TRBA, the process of mapping the
Claim ID to the related medical records.
xii. Facilities having electronic medical records, auditor should be given access to the visit information as required
for the audit and need not print the copies for auditor evaluation.
xiii. Facilities with paper medical records should arrange the total medical records related to provided claims for
audit within first one hour of audit start.
xiv. The auditing team may decide to perform any audit as on site or desktop/remote.
NOTE 1: Any delay in application resulting in missing the schedule will not be the responsibility of TRBA. Upon request,
TRBA may arrange for another schedule depending on the availability however, will not guarantee the continuity of
listing. The resulting gaps in listing will be the sole responsibility of the facilities.
NOTE 2: A maximum of 3 changes will be allowed for the nominees for interview and no changes shall be considered
1 week prior to the audit date. Any changes resulting due to emergency conditions shall be considered when provided
with supporting evidences to file in our records for such emergency conditions.
NOTE 3: In case of absence of nominees for interview after confirmation of the schedule, shall be considered as zero
for scoring, unless it is a documented emergency.
2.2.1 Special Requirements for Multi-Site Facilities
If a provider operates more than one facility, each facility must undergo the certification process individually. TRBA
prefers to proceed with individual contracts to avoid major changes in the contract and Tier. However, if the facility
still prefers for a group contract, it can be issued but the clause of change in tier system may change the price in
contract. Nevertheless, audit activities will be performed for each facility anyway and the policies can be verified once
unless there is any update;
Note: in case of centralized system, the auditor will verify if all facilities are following same methods and procedures
and the awareness and adherence of centralized policies and processes is verified for each facility.
2.3 Audit Sample Type for Claims Review
Random sample will be spanning across each major encounter type as applicable to the provider’s settings, to enable
meaningful coverage of sample distribution for audit. The random sample does not contain any identifiable patient
information.
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Example: A hospital that provides care in Outpatient, Inpatient, Emergency room, Day case and Home care settings,
five individual sets of claim samples will be audited.
2.4 Sampling method For Claims Review
A random sample of Dental and Self-Pay services will be audited if applicable.
i. The audit sample will include claims available from past 12-13 months from the audit date for certification or
re-certification
ii. Random sample size is as per the Tier system mentioned as tables in Appendix-I
iii. Each facility Tier information is provided by DoH based on volume of claims submitted to KEH during the past
12-13 months.
iv. Sampling is done using a scientific formula based on international best practices of accreditation.
v. The sample count indicated for each tier represents the sum of sample from all applicable encounter
types/settings.
vi. In case of insufficient number of claims in one specific setting, the difference of claim sample count will be
selected from another setting.
vii. Random sample contains a percentage of claims selected based on the specific quality criteria provided by
DoH.
viii. Random sample for Dental and self-pay services will be based on the specific applicable tiers.
2.5 Sampling for KPI Process and Validation:
For the KPI validation and process review, the audit will consider the typical third-party approach, that means sampling
could occur however sampling will cover all the applicable KPIs. This shall also include but not limited to disease
specific coding rules i.e. cancer, severity, cesarean, neonatal, complications etc., Sampling of KPIs for Data validation
can be done considering the high-risk indicators however, KPI process covers the whole Jawda KPI system
2.6 Random Sample Sharing for Claims Review:
• Random sample shall be shared only on the day of audit (except for Inpatient and Homecare/Long Term Care).
• Healthcare providers shall keep ready the process of mapping the medical records to the claim IDs to avoid any
delays in providing relevant medical records for audit.
• Claims directly accessible by claim ID in the health information systems without any need for mapping to medical
records need not be shared to the facility. However, facility will receive the list of evaluated claims with the
identified findings as an Annexure to formal report.
• The claims sample size for re-audits will be of Tier-1 of applicable setting.
• Claims samples from previous year after the issue of final report will be considered for re-certification.
Encounter Type
Setting
1
Outpatient
2
Emergency Room
3
Inpatient
5
Day case
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Home care
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• Claims samples from after the issue of final report of recent audit will
be considered for re-audits.
NOTE 1: Upon request, for physical medical records of Day-case the sample may be shared in the morning before the
audit team will arrive. Any delay impacting the audit schedule can result in incomplete audit and can impact the
scoring and, TRBA cannot be held responsible for such impact if any. All the medical records relevant to the list of
claims should be made available at the start of audit as 9:00 AM. Any unreasonable delays shall be impacting the score
and any delays causing the auditors to extend the audit time (including evidence collection) may incur additional
charges.
3 PERFORMANCE OF AUDITS
3.1 General
An “Audit Plan” is drawn up for each audit according which is sent to the customer facility in good time.
The audit has the following objectives:
a) Determination of the conformity of the client’s management systems, or part of it, with audit criteria;
b) Evaluation of the ability of the management system to ensure the client organization meets applicable and
contractual requirements;
c) As applicable, identification of areas for potential improvement of the management system.
The Audit Plan indicates the tasks assigned for audit. Specifically, for each facility covering the applicable domains:
a) the structure, policy, processes, records and relative documents to the applicable Management system must
be examined and checked;
b) it must be established whether these satisfy the requirements applicable to the scope of certification;
c) it must be established whether the processes and documented information are drawn up, implemented and
kept efficient, to nurture trust in the Facility's management system;
d) every inconsistency between the organization or facility’s policy, objectives, goals and the result obtained
must be reported to the facility (authorized representative) to allow for appropriate action.
e) Collecting audit evidences
f) Communication with the Head of the facility/ Representative along with the nominees mentioned on the audit
plan are seen to be required for opening and closing meetings to ensure a clear understanding of the audit
objective, process, identified findings and required corrective actions.
g) Presence of Top management for the closing meeting is important to show the commitment to continual
quality improvement of organization and to understand the areas of improvement and actions.
3.2 Audit Process:
The audit process will be conducted as per the audit plan starting with opening meeting, simultaneous request for
evidences and closing meeting.
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3.3 Audit Evidence Collection
i. Evidence of documentation, and identified deviations will be collected, as agreed in Provider Healthcare
Facility - TASNEEF contract. The evidence will be retained for a duration of maximum 2 years in accordance
with this
ii. All the documents reviewed in electronic format will be directly collected as evidence by the auditors
themselves. It shall be the responsibility of the facility to hand over all the other required documentation and
requested evidences before the auditor leaves the facility on the scheduled day and time. Facility cannot
extend the hours of auditor to collect the evidences.
iii. Failure to provide the requested evidences within the time shall be considered as non-compliance with
certification requirements and any documentations provided for any reason after the timeline cannot be
accepted. Audit and or certification process for such facilities may be stopped, as the audit process will be use-
less and ineffective.
iv. The Health Information Systems should have capability to electronic print/save the required visit documents
as audit evidences. Not having the option or such feature to provide evidence shall be considered as no
evidence provided and the auditor findings documented with specific reference remains valid.
v. It is highly recommended to provide evidences in electronic format to save paper and time.
vi. The evidences can be masked with confidential patient information retaining other required details of visit
and other pertinent information.
vii. It is the responsibility of the facilities to provide all the requested evidences of policies and claim related
documentations requested during the audit. Required evidences if found absent during reporting phase, will
be finalized based on the findings collected by auditors during the audit and cannot be negated by facilities.
viii. Protected health information of patient will be handled as per the required standards of privacy and security.
NOTE 1: It shall be the responsibility of the facility to acquire all the required approvals prior to the audit day as per
release of information to provide all the requested evidences on the day of audit with-out causing any hindrance to
the audit process. Failure to provide evidences on the same day shall be considered as breach in compliance to the
audit requirement and cannot be disputed.
NOTE 2: Any evidences missed from the list requested by the auditors will be a sole responsibility of the facility and
shall be considered as no available documentation during our further reviews and providers cannot comment or
disagree on the claims for which evidence is missing or not provided.
4 CERTIFICATION REQUIREMENTS AND GUIDELINES FOR CRITERIA
4.1 JAWDA Data Certification
DoH defines two key elements to quality in healthcare – Reliability and Excellence:
To obtain JAWDA Data Certification the facility must:
• Have established a Management System and kept it active in total conformity with the requirements of the DoH
JDC Methodology 2019.
• The management system is considered as being fully operative when processes, Verification Points and
documented information are established for the required domains of certification as per below:
• Claims review (Applicable for all facilities including Dental and Self-Pay)
• Clinical Coding Process Review ((Applicable for all facilities including Dental and Self-Pay)
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• “KPI” Process Review (relevant to Quality Indicators Data Submission)
• “KPI” Data Validation (relevant to Quality Indicators Data Submission)
4.2 Claims Review
Claims Review is one of the components of the JAWDA Data Certification. Claims review is a validation process to
review clinical documentation against the submission of reported clinical coded data by all healthcare providers.
Claims review does not exclude the activities billed with zero charges and cannot consider any exceptions for such
reasons.
JAWDA Data Certification will endeavor to strengthen the trust between payers and providers and to DoH by:
• Creating a shared understanding of the facility’s coding and physician documentation quality
• Giving the payers confidence that a facility is coding and documenting accurately
• Providing the facility with areas for improvement in the quality of coding processes
• Provides DoH a confidence that the submitted codes on claims that also forms the basis for KPI are accurate.
This involves the comparison of actual coding practices against agreed, documented, standards with the intention of
improving clinical coding data quality thereby improving quality of patient care. The purpose of the claim review is to
measure the medical record:
• to verify documented services provided to the patient,
• to verify the documented information describing the course of the patient’s condition and treatment and
• to verify the validity of billable services as per applicable guidelines
• to verify the quality of data being reported to DoH
4.2.1 Claims Review
TASNEEF will receive an audit sample as per the applicable Tier system through DoH portal for each type of setting
identified within the facility scope.
i. As part evaluation of the Clinical Coding and Data Process, TASNEEF Auditors should be provided with
complete access to data and documentation. Facility shall provide auditors with access to all the requested
information regarding the claims and process, not limited to any single visit or document. If required, auditors
can review the documentations of previous visits to form thorough conclusions required for complete
evaluations. Evaluation is not restricted to provided sample claims information only.
ii. A claim not identified during the audit or identified as missing record after confirmation with the audit
representative, will be considered as zero accuracy and completeness scores and should be documented. Any
documents provided after audit day shall not be accepted as documentation for review.
iii. Missing chief complaint on the visit documentation will be considered as “0” score, as a claim is not billable
without a chief complaint. However, a chief complaint can be considered if written in continuation as part of
history of presenting illness.
iv. Diagnosis in the final impression shall be as a narrative description and should be supported by documentation
details in the entire visit documentation (CC, HPI, PFSH, ROS, PE) to conclusion as diagnosis.
v. TASNEEF will then complete the audit in accordance with this methodology and collect audit evidences.
vi. All healthcare providers shall agree to provide with all the requested claims information, though previously
audited by TRBA, considering as an adhoc audit that can happen occasionally. This may involve same sample
or different sample or a mix of claims or any other verification as seen required.
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vii. The scoring against each criterion will be applied as per this
Methodology and the inclusive Error Scoring Tables in Appendix-III
viii. Claims review will be done applying the audit concepts and claims scoring criteria of this methodology.
ix. Errors related to deficient documentation of services, and procedures have specific categories in the error
scoring tables. These are considered as completeness error. It may be considered as accuracy error for future.
x. A claim can have both accuracy and completeness aspects applicable to same service or condition.
xi. The E&M Guidelines: The provider must state the E/M guidelines being followed as1995 or 1997. The use of
both guidelines is not allowed. (The E/M documentation cannot be a mixed template of 1995 and 1997/
Cannot mix body areas and body systems)
4.2.2 Classification of errors for Claims Review:
Errors are classified as Coding related, Documentation related, and Billing related.
Coding related:
• Any errors related to general and chapter specific guidelines of diagnosis coding.
• Errors related to procedure guidelines in coding.
• Documentation is more specific to code for a higher specificity.
• Evaluation and management services either missing or coded in high or low level.
• Incorrect diagnosis or procedures coded to the available documentation.
• Missing relevant or secondary diagnosis, additional diagnosis.
• Coding signs and symptoms, incorrect sequencing of diagnosis.
• Missing additional procedure codes.
• Coding possible, probable or questionable diagnosis.
• Minor procedure included in E&M or E&M included in surgical procedure.
• Missing medical necessity for the procedures ordered.
Documentation related:
• Any diagnosis or procedures are documented insufficient.
• Incomplete report or missing report.
• Documentation of problem(s) pertinent physician examination as normal.
• Documentation of extensive physical examination than required as per the complaints.
• Copy and paste of the same documentation.
• Chief complaint(s) not related to the primary diagnosis.
• Lack of more specific documentation when required to specify
• Lack of mentioning relationships of conditions as cause and effect or late effect or complication or resolved or
Due to.
• Any other abnormal clinical documentation.
Billing/Claiming related:
• Missing Per Diem codes
• Incorrect Per Diem or service codes.
• Missing no: of units of service codes.
• Missing anesthesia units.
• Claim submitted to incorrect setting as encounter type
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• Follow up within seven days’ period of the same complaint.
4.2.3 Claims Review Audit Verification Points and Scoring Criteria:
Claim level audit on random samples as per the guidelines mentioned in the methodology. The audit will focus on
claiming aspects as Documentation, Coding, Billing and Submissions and shall provide with scoring as:
a) Accuracy (ICD-10-CM, CPT 4th Edition for all services (including Radiology), USC&LS Codes, HAAD Service
Codes, HAAD telemedicine codes)
b) Completeness (ICD-10-CM, CPT 4th Edition for all services, USC&LS Codes, HAAD Service Codes, HAAD
telemedicine codes)
Claims review will output an Accuracy Score by assignment and reporting of only the codes and data that are clearly
and consistently supported by the health record documentation and in accordance with applicable code set and
abstraction conventions, rules, and guidelines.
Accuracy
Claims reviews will also identify clinical coding submission or improper documentation practices intended to
inappropriately increase reimbursement from payers or influence payer adjudication rules or deviating from the
guidelines or not accurately reflecting the services provided.
Completeness analysis contributes to recommendations on claims coding practices and does not affect the passing
criteria. It includes missing diagnoses and procedures that would have provided more detail on the condition or status
of the patient but would not have an impact of unusual higher outcome of reimbursement from payer for the services
provided.
The Completeness scoring will help determine and/or recommend improvements with regards to the reporting of
clinical coding and/or deficiencies in physician documentation.
i. The Accuracy and Completeness will be scored against the set of criteria, as supplied by Error Scoring Tables
of this methodology in Appendix-III.
ii. Coding based on incomplete documentations resulting in errors are scored as accuracy.
iii. Incompleteness of documentation by itself will be considered as completeness errors for tracking and
education.
iv. Completeness errors are limited to the details mentioned in the scoring tables.
v. The error scoring tables for outpatient are also applicable to Day case and Emergency.
vi. These scored errors have been rated by Diagnosis and by Procedures as Major, Moderate or Minor.
vii. Each record will start with 100 points for accuracy and 100 points for Completeness and the presence of any
errors will result in the deduction of the set number of points
viii. There can be no more than one error scored per code or one error per error-category in one claim for accuracy
scoring.
ix. Score will be deducted only once for the same error repeated in Claims under same authorization of home
health care.
x. All Completeness errors will be scored per each error irrespective of error category unlike in Accuracy.
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xi. The facility will be given an opportunity to review the individual
errors after sending the formal report and in case there is a difference of opinion in claims review where there
is a possibility of different coding outcomes based on a standard guideline or reference, it can be brought to
the notice of reviewer with a clear relevant standard reference. Only the comments with a justification
referring to any circular from DoH(HAAD) or published guidelines or standard coding guidelines will be
considered for review and response. It is to the sole discretion of the third- party audit body to decide based
on the applicability to consider the provided references.
xii. All grey areas in coding which are not addressed in coding manual or adjudication rules or DoH standards or
coding guidelines, should be mentioned in internal coding practice policy and procedures of that facility.
xiii. In case of no clear references available to both parties on the grey areas of coding concepts, the facility should
have a documented policy and a consistent implementation of such aspects in the facility to consider for the
benefit assignment. Otherwise, the conclusions made by the audit team shall remain applicable and facility
cannot be awarded with score benefit.
xiv. Only coding accuracy score shall impact the passing criteria.
xv. A coding completeness score for the facility does not have any impact for passing criteria and will be utilized
and recorded as a tool to track education requirements or coding process gaps for corrective actions for future
follow-up reviews.
xvi. Complete absence of claims during audit shall be considered for scoring as zero.
xvii. Report available only with diagnosis/prescriptions but without documentation of Chief Complaint/Review of
Systems/Physical Examination is also considered score as zero.
xviii. The scoring on each claim, is as per the error categories mentioned in detail as per the tables of Error Scoring
Table 1 to Table 8: Appendix-III
xix. Once each medical record has been scored, scoring weights equivalent to the ratio of claims distribution per
each setting will be applied and an overall claims review score is generated. (E.g. Inpatients-DRG, Day-case,
Outpatient clinics, Emergency and Home Care).
xx. Claims from dental and self-pay will also generate the scoring weights per claims ratio to the total claims.
4.3 Clinical Coding Process Review
Successful processes should be understood and followed by all involved. The facility will be rated on the facility’s
understanding and adherence to their process. The process of adherence check is to understand the deficiencies in
the Management System.
Coding processes will be audited at the facility to assess the establishment of policies based on standard and regulatory
requirements of HAAD Coding manual and normative references mentioned in this document, and adherence to it.
The Clinical Coding Process review is an integrated process evaluation for General, Dental and Self-Pay services.
However, all the applicable verification points will be evaluated for all applicable services.
Facility should be able to demonstrate the process being implemented for each service line (General, Dental, Self-Pay).
It is imperative that properly trained hospital staff are involved at the appropriate phases to ensure accuracy of
information reported on each claim.
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4.3.1 Audit Verification Points and Scoring Criteria:
i. Process flow chart reflecting the entire claims cycle. It can be a single flow map or multiple to reflect different
processes. However, there shall be at least one high level flow map reflecting all the functions and interactions,
and the details can be verified in the respective function flow maps.
ii. Updated and in-force policies as stated with reference to chapter 8 from Methodology standard
iii. Evidences of physician coder query process reflecting the start, course and end points of the query process
meeting the requirements of query as per HAAD code of ethics.
iv. Documents meeting the requirements of active Certifications and continuous education
v. In case of outsourced services, the outsourced party shall be responsible to submit all the required documents
related to their scope of work relating to methodology requirements, however, the final responsibility lies
with the facility
vi. Evidences establishing internal quality control process that can be requested by auditor from any quarter of
the year
vii. Evidences of coder interaction with related departments when applicable (Pre-authorization, Resubmissions)
viii. Interviews conducted to verify the adherence to policies and effectiveness of the process shall be documented
however, the observations identified during the interview process is related to appreciative quality or
perceptive quality and cannot be a matter of debate
ix. Any additional evidence required to represent the compliance to requirements can be requested by auditors,
hence evidences are not limited to documents as stated above
x. Sample verification of coding and documentation practices mentioned as requirements in the methodology
chapter 8. All the documents shall be legible and complete with facility name, date and required
authentications
xi. Any process being followed shall have documentations and lack of such evidences or records shall be
considered as non-conformity and receives a score deduction
xii. All the finalized nominees to be available as per the plan
xiii. Each aspect of clinical coding process review will be verified as applicable and in relevancy with Dental and
Self-Pay process.
xiv. Facilities should submit to TASNEEF, an action plan for resolving any major deficiencies identified during the
review. If requirements are not met by the next scheduled audit, DoH will be notified for further action. Impact
rating of non-conformities will affect certification.
Scoring of Clinical Coding Process Review:
• Deficiencies identified during the reviews of coding processes, policies and non-conformity of adherence by
relevant staff will be rated based on their impact, affecting the score.
• Observations made regarding the awareness of process and coding references cannot be contested as it is
unbiased appreciable evaluation.
• Clinical Coding Process Review nonconformities or deficiencies will have impact rating as Major and Minor which
will affect certification
• No separate score is generated for dental and self-pay Coding process review.
• Clinical Coding Process Review score is a consolidated score generated from comprehensive evaluation of
applicable aspects for general, dental and self-pay services, as applicable to the scope of facility.
• Claims process flow and effectiveness: (15 points)
o Coding Process Flow Chart/Map (5 points)
o Comparison of Flow map to the implemented process (2 points)
o Effectiveness of mentioned processes of functions (8 points)
• Training and orientation (10 points)
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• Policies and Practices review (40 points)
o Healthcare Documentation Policy and Practice review (16 points)
o Medical Records Policy and Practice Review (Interview) (12 points)
o Clinical coding Practices and Policy Review (12 points)
• Coder Credentials verification/Coding training (5 points)
• Process Compliance verification (30 points)
o Coder Observation (4 points)
o Physician Interviews (18 points)
o Claims Process (Insurance – Pre-authorization, Billing, Submission, Denial management) function Interview
(5 points)
o Finance Department Interview (Claims related) (3 points)
Note: Certified Coder Requirement
One of the following criteria must be met for the JAWDA Data Certification audit:
• have a Certified Coder with active status of AAPC or AHIMA (or) evidence of contracted outsourcing for coding
services, and the coder credentials of the coder representing facility for the scope of service from outsourced
company
And/or
• Action plan and evidence of progress to train and certify a coder within the facility in a specific time (maximum
1 year)
• Certified coder is not a requirement for facilities with exclusive dental services, however, a training on coding
guidelines for reporting ICD should be evident.
4.4 Process Review for: “KPI” Quality Indicators
The objective is to ensure the fundamental requirements are in place by ensuring that the measures necessary for
assuring quality and patient safety are in place with regards to structure, process and outcome. This is coupled with
the processes and policies needed to achieve a continuous improvement in our healthcare.
4.4.1 Audit Verification Points and Scoring Criteria:
The facility must make all necessary information available to TASNEEF for KPI planning for data collection and
submission as required by DoH and as stated in the methodology.
KPI Process Review will generate scoring for the evaluation on KPI Process for Planning, Support and Operations and
KPI Process for Quality Governance and Improvement as mentioned in the standard.
KPI Process for Planning, Support and Operations (50 Points)
i. Applicability of KPIs:
a. List of all applicable KPI approved by the top management with a profile for each KPI addressing- KPI
title, Description, Rationale, Target, Calculation, KPI Owner, Data Sources, Data Collection and
validation methodology, Data collection frequency, Inclusion/Exclusion Criteria, KPI Reporting
Frequency etc., (4 points)
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ii. Data Quality lead(s):
a) Documented appointment or assignment letter from top management (2 points)
b) Job description with Clear roles & Responsibilities relating to Jawda KPI and healthcare quality (2
points)
c) Training records on healthcare quality (2 points)
iii. Data collectors/validators:
a) Documented Appointment or assignment or nomination letter from KPI owner or Quality Lead (2
points)
b) Competency determined for personnel involved (To demonstrate the relevant criteria established
while nominating/assigning a role (2 points)
c) Training records (on data collection and/or validation methods) (2 points)
d) Performance evaluation at frequent intervals (at least annually, and with every new assignment to
ensure the collectors/validators performance) (2 points)
iv. Data Collection and Validation:
a) Approved Data collection and validation plan with defined components of data sources, frequency,
measuring tools, responsibility with well-designed structure for data collection (4 points)
b) Validation of collected data and Data can be traced to the source (2 points)
c) Completed data collection forms are signed off by the frontline KPI Owners prior to submission to
Quality Department. (2 points)
v. Corrective / Preventive action:
a) Approved Corrective / Preventive action policy (2 points)
b) Associated forms (1 points)
c) Corrective / Preventive action records (Ex: for Patient complaint etc., (2 points)
vi. Adverse and sentinel events:
a) Approved Adverse and sentinel events Policy (2 points)
b) Associated forms (1 points)
vii. Incident Reporting:
a) Approved Incident reporting policy (2 points)
b) Associated forms (1 points)
viii. KPI Report:
a) Statistics report generated from the health information system are reliable (2 points)
b) Report prepared in an organized document (1 points)
c) Names of the approval panel, designations, date of signature, signatures (2 points)
d) Review and Approval of CEO or Head of Facility prior to submission to DoH (2 points)
ix. Data Submission:
a) Filled data checklist and signed/approved (2 points)
b) Signed Log of submission with Date of submission (Non-Scoring)
x. Data Integrity and Backup plan:
a) Data privacy & confidentiality statement policy (2 points)
b) Approved Backup plan in place (2 points)
The healthcare facility should have in place established ongoing processes that are in alignment with the JDC
certification needs as per Chapter 10 of JDC Methodology part 1.
KPI Process for Quality Governance and Improvement (50 Points):
i. Management review:
a) Management Review Policy and Report (Management Review in alignment with clause 10.3) (2 points)
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b) Annual meeting plan and Meeting agenda (Quality topics
such as KPIs progress, Trend analysis, Complaints management process, patient satisfaction, Facility
performance on JDC management system etc. …) (2 points)
c) Approved minutes of meeting (2 points)
d) Corrective / Preventive action (2 points)
ii. Quality Committee / Medical records Committee / Any Relevant Committee:
a) Committee Policy/Internal Memo (2 points)
b) Terms of reference include Purpose, Objective, Membership, Declaration of Conflict of Interest, Duties
and Responsibilities, Authority, Distribution of minutes. (2 points)
c) Annual meeting plan (2 points)
d) Meeting Agenda with Approved minutes of meeting (signed by members and chairman) (2 points)
e) The minutes of meeting.
a. Minutes should be clear and includes the assigned person and action to be taken. (2 points)
b. The minutes should also include the review of the last minutes and items discussed should be
relevant. (2 points)
c. The minutes of meeting for the Quality Committee and/or Medical Records Committee are
available, latest one being no less than 90 days from day of inspection (2 points)
iii. Staff Awareness/communication (Data collection and validation Process, Trend analysis, Progress, Calculation,
Lessons learnt, Improvement etc.,):
a) Approved policy/procedure (2 points)
b) Annual regular Internal communication plan (2 points)
c) Minutes of Staffs meeting (2 points)
iv. Quality monitoring:
a) Approved Quality policy (2 points)
b) Quality program includes the organization mission, vision, values, quality model, quality and patient
safety framework, responsibility/ accountability structure, etc. (2 points)
c) Quality monitoring records and Quality Improvement process – actions /records (consider also criteria
from 10.4 and 10.5) (4 points)
d) Corrective / Preventive action (2 points)
v. Internal Audits:
a) Approved Internal Audit Policy (2 points)
b) Jawda KPI policies and performance audit (Planning, Checklist, Findings, Report, consider also criteria
from 10.2) (4 points)
c) Corrective / Preventive action (2 points)
vi. Jawda KPI Risk management: Documented risk assessment (Also refer to Chapter 6 & 10.4)
a) Approved risk Assessment Policy (2 points)
b) Approved Mitigation Plan for all identified risk (2 points)
KPI Process Review for Home Health Care, Long Term Care, Rehabilitation Hospitals is same as the review process for
General and Specialized Hospitals.
Each verification point under KPI Process for Planning, Support, Operations and KPI process for Quality Monitoring &
improvement is assigned with distribution of given scores. Every conformity will be assigned with full points, non-
conformity with no scoring points and a partial conformity with partial score.
KPI Process Review has a weightage of 25% for the overall Final Score.
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4.5 KPI Validation for Collection and Submission of Jawda
Quality Indicators
The vision for the Health System in Abu Dhabi is to provide access to high quality healthcare services to all. To achieve
the vision a common language was developed and a standardized way of exchanging data.
As healthcare moves forward with initiatives such as quality-driven reimbursement and clinical quality measure
reporting, both organizations and physicians must provide justification for patient care and demonstrate quality
outcomes.
KPI validation is a method to verify if the information collected from the Hospitals for HAAD Quality Performance KPI
Profile program has an objective evidence to confirm that the requirements which define the intended use have been
met.
4.5.1 Audit Verification Points and Scoring Criteria:
Jawda KPIs from all the sub-Domains will be verified as per the applicability of KPI profiles and per the facility type.
The different verification points, as applicable, are but not limited to the calculation of:
a) Count/Numerator
b) Inclusions Numerator (when applicable)
c) Exclusions Numerator (when applicable)
d) Denominator
e) Inclusions Denominator (when applicable)
f) Exclusions Denominator (when applicable)
g) Calculation
h) Traceable data elements and Regeneration of report
i) Timelines of Submission (Non scorable as the submission is according to the window period)
The facility should be able to re-generate the reports of KPI from a randomly selected duration as submitted to DoH.
• All relevant KPI indicators are validated for accuracy of the submitted data against the applicable KPI criteria and
reliability of the submitted data.
• KPI Data Validation is categorized for scoring as Met/Partially Met/Not met resulting in score assignment.
• Depends on the variables (Count/Numerator…….) applicable as per definitions.
• Each indicator is considered with maximum 100 points which is equally distributed across all applicable
verification points as mentioned in 4.5.1.
• Example 1:
QI001: Total score points assigned -100,
• Count/Numerator-25 points; Calculation criteria applied-25 points, Traceability-25 points; validation-25 points
• Example 2:
QI005: Total score points assigned -100
• Numerator: 16.67 points
• Numerator exclusion: 16.67 points
• Denominator: 16.67 points
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• Denominator exclusion: 16.67 points
• Traceability: 16.67 points
• Validation: 16.67 points
• Every conformity will be assigned with full points, non-conformity with no scoring points and a partial conformity
with partial score.
• Aggregate score of the evaluated KPI will generate score for a total of 100.
• KPI Data Validation has a weightage of 25% for the overall Final Score.
• The validation shall be done for all the applicable subdomains of indicators such as but not limited to, Adverse
Events & Sentinel events, Patient Safety, Effectiveness, Effectiveness/Process, Emergency, Complication,
Complication/Outcome, Readmission, Clinical Effectiveness, Prevention, Timeliness, Recovery and Disability,
Admission, Recovery, Evidence Based Medicine, Healthcare associated Infection, Mortality, Safety/Environment
and Timeliness as waiting time. (e.g. waiting time indicators, adverse incidents and outside critical care cardiac
arrest, Worsening Pressure ulcers etc.,).
At least one Ad-Hoc KPI audit shall be performed on each facility (Hospitals) in a year which will follow the same
methodology and Ad-Hoc audit specifications will be as per the agreement with DoH.
Ad-Hoc audits will be as un-announced visits and the facilities are requested to extend complete co-operation to the
auditors without causing any delays.
The score generated from this audit is not related to JDC.
All costs relative to ad-hoc KPI audits, as per the methodology and directions of DoH will be charged to the facility.
Additional Ad-Hoc audits could be performed by the certification body upon the request of DoH.
5 DENTAL SERVICES
Clinical Coding Process Review will be conducted for facilities with exclusive dental services and shall generate an
individual score for 100.
For facilities with dental services as additional scope, clinical coding process review of dental will be conducted as an
integrated process review.
5.1 Audit Verification Points:
A. Process review:
Includes verification of policies and processes for the below data points as documented in chapter 4.2 and 4.3,
applicable as relevant:
i. Medical records policies and adherence
ii. Documentation policies and adherence
iii. Coding and Claiming processes and practices including consents and pre-authorizations
iv. Universal Dental Charting
v. Clinical Coding Process Review score is a comprehensive score from evaluation of process (general/
dental/ Self-pay) as applicable.
vi. Clinical Coding Process Review for Dental is integrated with general services unless the facility is
exclusively dental service provider.
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B. Claims review:
i. There are no minimum required claims count to conduct audit on dental claims for the first year or
until further change.
ii. A distinct random sample of dental claims shall be provided by DoH per tier system of medical centers
if applicable.
iii. To verify the documentations, consents and approvals for the submitted claims as per the Canadian
classification system
iv. Physician documentations are verified in detail to support the provided services and assigned codes
shall be thoroughly reviewed.
v. Claims review score is a weighted score proportionate to claims ratio
vi. A score shall be generated based on identified error scoring criteria for claims and coding process.
vii. The facilities with passing score will be listed on Shafafiya with the scores achieved.
viii. Follow-up audits shall be conducted when a facility has achieved score greater than or equal to 86%
but still have many major non-conformities to be rectified.
ix. Re-audits shall be conducted for facilities where the score achieved is less than 86%.
6 AUDIT ON SELF-PAY SERVICES/PROFORMA SERVICES
With reference to Data Reporting requirements as stated in Healthcare Regulatory Policy Manual Chapter-6 Data
Management, all Healthcare Providers and Healthcare Payers must submit healthcare data to DoH, as specified in the
HAAD Data Standards and Procedures.
• All the healthcare facilities which are already in the scope of JDC audit with medical/surgical claims shall also be
in the scope of audit.
• Audit for Self-Pay services or Proforma services is mandatory
• Facilities with exclusive self-pay/proforma services are applicable for self-pay specific tier system (Tier-SP) and
listing on Shafafiya
• Clinical Coding Process Review and Claims review will be conducted as per the exclusive
• The audit process for proforma payers (services which are not paid either by patient or insurance companies) is
same as the self-pay audit process and self-pay tier system and prices are applicable.
• Audit for Self-Pay services generates score which is inclusive of overall JDC score and shall be updated as listing
on Shafafiya. Additionally, all the facilities scores shall be reported to DoH for their further actions and
proceedings in case if any
• Follow-up audits shall be conducted when a facility has achieved score greater than or equal to 86% and still
have many major non-conformities to be fixed.
• Re-audits shall be conducted for facilities where the score achieved is less than 86%
6.1 Audit Verification Points:
Claims review: All applicable guidelines of JDC criteria for claims review is applicable
Claims review:
• There are no minimum required claims count to conduct audit on self-pay claims for the first year or until further
change.
• A distinct random sample of self-pay claims shall be provided by DoH per self-pay tier system.
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• To verify the documentations, patient consents and bills of the
rendered services to the submitted claims information.
• Physician documentations are verified in detail to support the provided services and, assigned codes shall be
thoroughly reviewed as per applicable coding guidelines.
• A score shall be generated based on identified error scoring criteria for claims and coding process however, the
facilities shall be recorded on Shafafiya certified facilities list with the scores achieved and results shall be notified
to DoH for required actions or decisions.
• Facilities that have other general and or dental services in addition to self-pay, will generate an overall JDC score
where the clinical coding process review score is a comprehensive score from evaluation of process (general,
dental, Self-pay) as applicable and Claims review score is a weighted score proportionate to claims ratio.
All costs relative to audit on any Self-pay services will be charged to the facility
Process review: Clinical Coding Process Review for self-pay is integrated with general services unless the facility is
exclusive provider of self-pay services. All applicable guidelines of JDC criteria for Clinical Coding Process review is
applicable
Clinical Coding Process review shall be conducted on the Medical records, Data collection, recording, documentation,
Coding and billing and Claim submission process as documented in chapter 4.2 and 4.3, applicable as relevant.
7 REPORT
All the audit activities (Reviews, Validations and Process Reviews, for Claims and KPIs) will be performed according to
the plan with facilities as per the audit plan.
Upon the completion of the audit of the Facility, a copy of the written report will be delivered by Lead Auditor of TRBA
to the authorized representative responsible for the facility, for understanding and acknowledgement of the report
and required action plans with-in 2-3 weeks from the audit date
The formal report with acknowledgement should be endorsed by the CEO or CFO or COO delegated authority of the
facility and should be submitted to TRBA for final decision.
The Formal endorsed report will be for the review of Certification Controller and for final decision from TRBA in
collaboration with DoH.
The original audit report is owned by the certification body.
The facility may indicate any reservations or comments concerning the findings by the TRBA auditors in the relative
space in the audit report. Only concerns with references to standard guidelines (Regional or International) from Claims
review criteria-General/ Clinical Coding Process Review- Criteria or DoH (HAAD) circulars shall be reviewed and the
conclusion shall be communicated in the final report. Comments with absence of such references does not be deemed
to provide any response.
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Considering the audit as Third-party concept, the comments from facility
cannot be as a dispute or on- going discussion. TRBA reserves the right to make a decision after careful consideration
of valid comments from healthcare facilities.
The final report will be issued prior to listing expiry, and facilities with late applications or delayed audit process will
receive the final report within 30-40 working days from the date of the audit completion.
Any delay in reporting from TRBA from the specified timeline, TRBA shall inform the facility and assures that there will
be no negative impacts on the listing resulting due to delays.
There cannot be any scope for reviews or revisions after the issue of final report.
The Final report will include:
• Scoring for claims review
• Scoring for Process Review – Clinical Coding
• Scoring for Process Review – KPI (applicable as per JAWDA program)
• Scoring for KPI data validation (applicable as per JAWDA program)
• Improvement areas
In the event of several major non-conformities, the certification process requires an extra visit for process review; this
follow-up audit must be performed within two months to check the effectiveness of the proposed corrective actions;
All costs relative to any follow-up audit deriving from shortcomings in the Management System will be charged to the
facility.
7.1 Audit Report Format
The Final report includes:
1. Over all report summary as PDF or Word with JAWDA Data Certification - Final Score and Grade, Annex-A with
Facility Comments and Corrective Action Plan, Annex-B with Scoring Details of claims review score, Process
review score and KPI Process Score, KPI data validation score.
2. The Process Review Details in the Final report includes:
a. Gaps or deficiencies identified in the process
b. Coding Policies review
c. Coder certification validation and observation
d. Summary of Claims Review findings
e. Identified non-conformities of compliance to policies and process flow by relevant personnel.
f. Improvement Areas: based on process, policies and compliance check
g. All extenuating circumstances if any, that have been verified and validated by TASNEEF
3. Claims review details of Formal Report must include:
a. A Cover page from DoH with Facility Name. license and Audit Type.
b. Each additional Data sheet(s) for each setting as Inpatient, Outpatient, Emergency, Day-case/
Homecare or Telemedicine /Dental/Self-Pay with:
i. The full list of all claims/encounters audited
ii. Claim Id
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iii. Date(s) of encounter
iv. All CPT codes and descriptors, including E&M codes if applicable, except ancillary services (i.e.,
Laboratory and Pathology) and Green Rain Drug Codes.
v. All ICD-10 CM codes and descriptors indicating the Diagnosis type as principal and secondary
codes etc.
vi. Details of error, corrections, with codes, descriptor, Auditor Comments, error categories and
scores on each claim reviewed, Reference Criteria, Coding and/or Documentation error
classification, Additional comments, if any
vii. Scores following the specified scoring methods and points with totals for each department
c. KPI Process Review findings- Applicable KPI findings on KPI process will be provided with the non-
conformities as major or minor
d. KPI Validation findings- Data validation for the verified KPIs will be reflected as scores
Facility should respond to TASNEEF through e-mail with a definitive action plan to resolve the identified non-
conformities in process, within 5 calendar days after receiving the formal audit report. Any delay in sending the
corrective action plan may delay the final audit report and result. Such delays resulting in any gap in listing or any
other impacts shall not be the responsibility of TRBA.
Note 1: Additional Error Classification: To help overall reflection of concerned areas for improvement and to
understand how each error is contributing to the score, identified coding errors will be additionally classified as Coding
errors and/or Documentation based errors.
8 NON-CONFORMITIES AND CORRECTIVE ACTIONS
Each aspect of mentioned domains for audit shall be verified for conformance to the requirements of applicable
standards.
Clinical Coding Process Review and KPI Process Review will be verified for conformance and the report shall clearly
indicate the non-Conformities.
Claims Review will be verified for conformance to the relevant criteria and non-conformance is recorded with score
deduction according to the scoring Tables published in the Appendix-III
KPI Data Validation shall be verified for the conformance of submitted data to the accuracy required as per the DoH
KPI profile. Nonconformities for KPI Data Validation shall be recorded with score deduction.
Conformity: - Has an objective evidence of conformity to standard requirement Non-Conformance is categorized to
Major and Minor.
Major Non-Conformity: A fundamental or important issue that requires an action as soon as possible without which
a process may result in unproductive or ineffective outcome.
Minor Non-Conformity: An issue, resolution of which would improve overall effectiveness / efficiencies of the process.
All the Major Non-Conformities must be rectified with a corrective action plan.
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Minor Non-conformities, can be verified for the root cause and to be
rectified.
Corrective Action: Corrective actions are steps that are taken to eliminate the causes of existing nonconformities in
order to prevent recurrence
Corrective Action Plan: A step-by-step plan of action and schedule for correcting a process or area of non-compliance.
The corrective action should provide information as to What is the non-Conformance, identified Root cause, what is
the corrective action, who is responsible for the corrective action, when is the corrective action targeted to be
completed.
As per the International standards and best practices, a target date of corrective actions to be implemented is set to
be within a maximum of 90 days.
The Leadership of the organization should understand, acknowledge and assume the responsibility to monitor the
corrective actions and ensure the conformance.
After analyzing the reasons for any major or minor observations indicated in the above report, the Facility must, within
the data indicated on the report, inform TASNEEF of its proposals for handling the observations, as well as the
corrective action required, and the dates envisaged for its implementation.
Any disagreements documented in the corrective action plan are not considered as a corrective action, a proper
corrective action is required to be submitted and thus not meeting the requirement of effective completion of audit
process.
• A moderate non-conformity in the previous audit is identified as Major if the corrective action plan is not
implemented. There is no moderate non-conformity in this version of methodology.
• The auditing team may decide to perform any audit as on site or desktop/remote.
• Facility can apply for re-audit after 60 days (from day of audit/result) by submitting the proof of corrective actions
9 WEIGHTS AND SCORING
i. The final score will be weighted per the facility type, domains and services.
ii. Examples of Domain weightages and Scoring Details can be seen in the tables in as shown in Appendix II. The
passing scores for claims review, process review of clinical coding, process review for KPI and KPI data
validation will be communicated annually from DoH.
iii. The current passing score is 86% as an overall accuracy score.
iv. Clinical Coding Process Review is a comprehensive process review covering general, dental and self-pay
services that generates an integrated score out of 100.
v. Claims review scores of General, Dental and Self-Pay are weighted scores per the claims ratio.
10 DECISION MAKING
TRBA reviews the submitted Formal Audit Report referring to the collected evidences and issues a final report with
Final Audit Score details and acknowledging the corrective action plans. TRBA reserves the right to reject the corrective
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action plans if supposed to be not meeting the requirements of corrective
actions and any disagreements on auditor findings. Facility can request for more details to understand the non-
conformity to provide the corrective action plan.
The facilities will be graded based on the scores achieved and the certification validity is as per the grades obtained.
10.1 Passing Grade system for JAWDA Data Certification
Grades and validity based on accuracy scores
• The passing grade for all facilities is based on the Final score which includes as a comprehensive score of
individual Claims Review, Clinical Coding Process review and, additional score for Hospitals, Home Health Care,
Long term Care, Rehabilitation facilities as KPI Process Review, and KPI Data Validation.
• The facility should score an overall Accuracy Score of minimum of 86% in total, as per the weights explained in
Tables of Appendix-II.
• The validity of certification is based on the grades linked to the scoring achieved.
• There will be a bonus validity for high scores and reduced validity for lower passing scores.
11 RE-AUDITS
The facilities that could not meet the passing criteria will not be published on the Shafafiya Certified Facilities list.
i. Re-audit will be done only for the problem area, where the score of individual domain is less than 86%.
ii. If a facility has scored less than 86% in process review and scored more than 86% in claims review and KPI,
then re-audit shall be conducted only on Process review after 1 months from the date of audit result. The gap
in listing will be approximately of a month.
iii. As the process review is comprehensive, all the major non-conformities will be reviewed during the re-audit
irrespective of general/dental/self-pay.
iv. If score of Dental/Self-Pay/Proforma claims review is less than 86, re-audit will be conducted only on that
service claims.
v. If the facility has passed in process review and KPI but scored less than 86% in claims review, then the re-audit
shall be conducted only on claims review “after 2 months” from the date of audit result. The gap in listing will
be approximately for 2 months.
vi. If a facility has failed in both process and claims review and passed in KPI, re-audit shall be conducted on both
the problem areas “after 2 months” from the audit result date. The gap in listing will be approximately for 2
months.
vii. The claims sample will be as per the least tier sample of applicable facility type
viii. Claims Sample is selected from the period after the issue of final report.
Accuracy Score
Grade
Validity
96-100
"A"
18 months
90-95
"B"
12 months
86-89
"C"
9 months
<86
"D"-Failed
Re-Audit
29
ix. Prices for Re-audit are separate for Process review, claims review and
KPI and are fixed per facility type.
x. Facility should ensure the relevant personnel were trained on the recommended areas of improvement.
xi. Revised policies and processes per the standard requirements of clinical coding to proceed for a re-audit.
xii. Facility can apply for re-audit as per above mentioned timeline by submitting the proof of corrective actions
or a letter of request stating readiness for re-audit (in case of re-audit only for claims review).
xiii. Facility should respond to TASNEEF through e-mail with a definitive action plan to resolve the identified
deviations in process, within 5 calendar days after receiving the formal audit report.
xiv. If a facility has scored less than 86% in KPI process review and scored more than 86% in KPI data validation,
coding process review and claims review, then re-audit shall be conducted only on KPI process review after 1
month from the date of audit result. Facility shall request for re-audit after implementation of corrective
action plan. The gap in listing will be approximately for 1 month.
xv. In case of facility failed only in KPI Data validation, as there will not be any KPI reports available for re-audit
with-in 2 months, facility shall be listed under “Conditional listing”. Re-Audit will be done when a new
submission of KPI data is available (approximately after 5-6 months). If failed in re-audit, back dated de-listing
will be done.
xvi. If a facility failed in both KPI process review and data validation, then re-audit shall be conducted on KPI
process review after 2 months from the date of audit result and facility shall be listed under “Conditional
listing” if the facility scores more than or equal to 86% in KPI process review. Re-Audit will be done when a
new submission of KPI data is available (approximately after 5-6 months). If failed in re-audit, back dated de-
listing will be done.
xvii. Listing after passing in Re-Audit will be done after adding the scores of other passed domains and grade shall
be assigned based on overall score.
xviii. There will not be any temporary listing for re-audit other than “Conditional listing” for KPI data validation.
12 LISTING AND DE-LISTING
• The issuing of certifications and recommendations are the sole responsibility of TASNEEF based on facts.
TASNEEF will provide the information to DoH to be published in the listing as they see fit.
• Facilities with The Certification Effective Date is date of publication on the Certified Facilities List on
www.haad.ae/datadictionary
• The Certification Expiry Date is based on the grades obtained.
• This issue of Certification shall be forwarded to DoH, as applicable, and will be within 30-40 working days of
receipt of the completed audit by TASNEEF, as applicable per the general terms and conditions of annexure for
this methodology. The reflection of the results on the DoH website is subject to date of upload of updated listings
by DoH.
• It is the responsibility of the healthcare facilities and Payers to review the published list to ascertain pertinent
information on scores and/or coding certification validity.
• It is also the responsibility of healthcare facilities to apply for renewal certification 2 months prior to the
certification listing expiry.
• If the Audit fails to meet the scoring criteria, after being reviewed by TASNEEF the re-audit criteria is as per
Chapter 11 of this methodology.
• The list of certified facilities will consist of three parts:
• New facilities listing (see TRBA website for New Facility listing guidance and process)
• JAWDA Data Certified Facilities 2018
• JAWDA Data Certified Facilities 2019
30
• TASNEEF retains the right to revoke certification of a facility based on
substantive evidence that the audit of this facility was not representative of actual coding practice. There must
be evidence of improper conduct which may include but is not limited to:
• Evidence of documentation manipulation
• Evidence of bribery or collusion
12.1 Impact of De-listing (Gap in Listing)
• Facilities shall understand that the gap in the listing resulted due to unsuccessful outcome of JDC audits might
have an impact on the reimbursements from the payers or may have an impact on their participation to Health
Insurance scheme, not mentioning the level of impact.
• Any gaps resulted in the listing of the facility due to late applications, missing audit schedules, or for any other
delays or reasons caused by facility will not be the responsibility of TRBA.
• Delay in sending the corrective action plans resulting in gap of listing is the sole responsibility of the health care
facility.
• Request for early schedules or schedules nearing to the existing expiry of listing may not be accomplished or
provided due to unavailability of calendar schedules. Gaps resulting from such delays is a sole responsibility of
the health care facility.
• Listing is provided from the date of audit to the new facilities who have no prior certification listing.
• New facilities proceeding for early audit schedules shall be listed as JDC certified from the date of audit, though
they have a valid listing for another few months. Such listing of new facility shall be overlapped with the JDC
certification listing.
• Facilities who have got certification previous year, but unable to proceed with certification due to less claims
shall still proceed with certification to maintain continuity of listing provided they have a minimum sample of
30, putting into consideration that the facility may make up for more claims in the later part of the year and shall
not incur gap in listing, unless the facility choses to proceed with the listing gap, such action implies
understanding of implications of liabilities resulting from claims process.
13 TRANSITION PHASE OF OLD TO NEW METHODOLOGY:
The New JDC Methodology of 2019 is applicable for the facilities for which the audit is conducted from January 1st,
2019.
14 MAINTAINING VALIDITY OF THE CERTIFICATE
The facility must ensure its System continues to comply with the Methodologies and other applicable reference
standards or regulatory document. The facility must record any complaints / claims and the relative corrective action
implemented and must make these records available together with the corrective action taken to address the
identified deviations.
TASNEEF also reserves the right to perform additional audits based on the impact of identified deviations in the
processes. Also, reserves the right to perform and charge Re-audits on failed facilities.
31
• May conduct a follow-up audit to confirm that the major deviations
identified during the initial audit have been corrected by facility as per the action plan. Action plan should be
sent by the facility to TASNEEF giving the details of action for corrections with-in a week after initial audit.
• TASNEEF shall conduct a Re-audit on failed facilities as required on Process or Claims review. Re- audit on Clinical
Coding Process review is to verify the corrected Processes as per the action plan within two months’ duration
after audit.
If the facility refuses without a justified reason, TASNEEF may decide to suspend/withdraw certification.
14.1 Management of Certificates
1. The validity of the certificate is based on the scoring achieved by the facility
2. The validity of the certificate, could be subjected to the results of the subsequent audits.
3. The validity of the certificate may be suspended, withdrawn or relinquished
15 MODIFICATION OF CERTIFICATION AND COMMUNICATION OF
CHANGES
1. The facility must promptly inform TASNEEF of any changes in factors that may affect the capacity of the
Management System to continue to satisfy the requirements of JAWDA Data Certification.
2. These requirements concern, for example, modifications to the legal, commercial, facility or ownership status.
3. TASNEEF reserves the right to perform additional audits on the facility if the modifications communicated are
considered particularly significant in regards maintaining the conformity of the Management System with the
requirements of the reference standard and of these rules or to review the economic conditions for the
possible modification of the contract.
4. TASNEEF promptly informs the facility whenever any changes in the methodology, reference standards or
certification rules are published.
16 CONDITIONS AT WHICH AUDIT PROCESS WILL STOP
1. When required evidences are not provided on time (within the end of the audit time) as per the schedule for
the audited function which leads to losing of audit time consequently audit process will be un-useful and
ineffective
2. When the auditor faces difficulties to get and collect the relevant evidences at the time of audit (i.e. collection
will be latter after the audit) which might lead to improper conclusion of audit findings
3. When the planned nominated personnel are not available and the one provided is not competent to provide
the required evidences or to demonstrate responsible attitude, consequently audit process will be useless
4. Absence of authorized person from the top management who is authorized to facilitate the audit process with
the competency and authorization levels that help him to understand, response, discuss, agree and sign the
concluded findings during the whole audit process (i.e. from planning till audit report and certificates
submission)
5. Any case that might be classified by the lead auditor to lose the professional objective of the audit process
and provide unprofessional services like:
i. Unavailable agreed resources with the client like proper adequate and comfortable room space for
the auditors, access to review the required medical records or documentation
32
ii. Unavailability of required employees for the audit per the
agreed plan communicated with the client, especially when no concern is received from the client side
after plan communications
iii. Any interaction from unnominated auditee which will not pour in the sake of audit and may adversely
effect on the auditor ability to conclude proper and professional conclusions.
6. If due to emergency situations TRBA auditors couldn’t join the audit as per the planned arrangements client
will be communicated to set another audit plan
7. Cases from 1 to 5- Client will be charged for compensated new planned time to complete the audit process
8. Case no. 6- TRBA will reschedule audit time compensation before certification expiry date.
17 CONDITIONS AT WHICH CERTIFICATION PROCESS MAY BE
SUSPENDED
1. In cases when the audited facility cannot provide the evidences before the completion of the audit time.
2. In cases when TRBA will reject the facility proposed corrective actions not resulting in effective solution for
identified non-conformities.
3. In case of not sending the corrective actions plan in the 5 Calendar days of sending the formal report.
18 SUSPENSION, REINSTATEMENT AND WITHDRAWAL OF
CERTIFICATION
The validity of the certificate of conformity may be suspended as indicated in “GENERAL TERMS AND CONDITIONS”
and in the following specific cases:
• if the Facility refuses to allow the scheduled audits to be performed at the required frequencies;
• if observations are found in the management system which have not been corrected within the time limits
established by TASNEEF
• if the facility does not observe the deadlines established for the communication of corrective actions, following
observations/observations indicated on the audit report;
• for evidence that the facility does not guarantee the respect of the laws and regulations applicable to the
supplied services or activity
• if any justified and serious claims received by TASNEEF are confirmed.
The facility may also make a justified request to suspend certification, normally for not more than six months and in
no case after the date of expiry of the certificate.
This suspension will be notified in writing, stating the conditions for re-instating certification and the date by which
the new conditions are to be complied with.
Revocation of the certificate of conformity may be decided in the following specific cases:
• if the facility does not accept the economic conditions established by TASNEEF due to a modification in the
contract tariff, approved with DoH
• for every other major reason, at TASNEEF 's discretion, such as the proven incapacity of the system to pursue its
objectives of complying with legislative, contractual requirements.
33
Withdrawal of the Certificate of Conformity is notified in writing to the
Facility and made public in DoH website
Any facility which, following revocation of its Certificate, wishes to be re-certified, must submit a new application and
follow the entire procedure all over again.
19 RENUNCIATION OF CERTIFICATION
A certified facility may send formal communication of renunciation of certification to TASNEEF in case of business
termination before the expiry of the certificate.
Upon receipt of this communication, TASNEEF starts the procedure for invalidating the Certificate. Within one month
from the date of the communication, TASNEEF updates the validity status of the certificate.
20 NEW FACILITY LISTING AND EXTENSION OF LISTING
New Facilities Listing:
a. Any new facility including Dental Centers and Self-Pay must apply for “New Facility Listing” within 6 months
of obtaining their HAAD license.
b. Facilities which have been operating over 6 months after obtaining HAAD license should present an
explanation letter for the delay in request.
c. Every request for New Facility Listing should be accompanied with the following documents:
i. A copy of the valid HAAD facility license
ii. The Facility’s CODING Process Flow Chart or policy
iii. A letter stating all the above as well as a summary description of the coding process flow in this facility
iv. Proof of Coder (internal or outsourced, as applicable) current certification and/or experience (proof
that the certification is current and valid)
v. Proof of current Continuing Education of the coder vi. If applicable, a copy of the coding outsourcing
service contract with companies.
d. Once the documents are reviewed and if these meet the criteria as specified in this Methodology, the facility
will be listed in Shafafiya with validity of 6 months.
e. All Listed New Facilities should be able to proceed for JAWDA Data Certification process once the facility has
submitted a minimum of 120 claims in total scope. For Hospitals, facility shall apply for an audit after
submitting a minimum of 120 claims for each setting or completing six months of claim submission irrespective
of claims count per settings, whichever is earlier. If by the date of expiry of initial listing the facility does not
have sufficient number of claims, it can apply for extension as described below.
f. If a facility is not new and submitted some claims previously or years ago, facility should provide a reason why
the facility could not maintain the certification continuously or the reason for the gap years.
g. The reason will be reviewed by DoH and/or TASNEEF, and a final decision of listing under exemption will be
given.
Extension of New Facility listing
a. After 6 months of new listing, if the facility is unable to start claiming process or could not meet the criteria of
120 claims for each facility setting to proceed for certification, an extension request should be sent to TRBA
executives assigned to your facility.
34
b. Facility should provide a justification letter for the request of
extension in listing.
c. The justification will be reviewed by TASNEEF and after confirmation from DOH that there are no enough
submitted claims, the extension will be issued in the list of Certified – New Facilities list.
d. The duration of the extension period may vary from 3- 6 months based on the submitted claims count. New
facilities proceeding for early audit schedules shall be listed as JDC certified from the date of audit, regardless
of the remaining months of the current listing. Such listing of new facility or extension of listing shall be
overlapped with the JDC certification listing.
e. Not more than 2 extensions of 6 months validity will be provided. Facility should be audited prior to the expiry
of extension listing if the facility claims submission count meets the required sample and, need not necessarily
meet 120 claims.
f. Any case where the facility has not initiated any claims submission, should submit the supporting
documentation as justification for the request of further extension as a special case.
21 COMPLAINTS MANAGEMENT
TRBA has always considered complaints and customer satisfaction as an incentive to improve the quality of the service
provided. This chapter describes how third and interested parties can file a complaint with TRBA concerning its
activities. All the complaints should be sent to email ba.jdcsupport@tasneef.ae Complaints routed through this email
will be responded as per the complaints management procedure. The communication must include all the data
enabling TRBA activity for which a complaint is being filed to be identified. The specific aspect of complaint for review
will be identified, and a receipt notification will be sent to the facility within 5 working days describing the request
management process.
Some of the critical comments are managed directly in the phase of the formal report as per the following points,
however complaints, observations and request could include aspects of the certification process more in general.
As per reporting process:
1. All the audit findings are communicated to the facilities in the formal audit report and any concerns on the
communicated findings can be flagged for additional review with appropriate justifications referring to specific
guidelines and/or standards.
2. All the facility comments mentioning relevant references, guidelines and with appropriate justifications shall
be reviewed to provide response in the final audit report.
3. All the evaluations shall be done as per the methodology criteria and normative references. In case of
evaluations that are not justified in the final audit report, resulting in failure of audit results, facility can request
for a meeting with TRBA to further understand the facility point of view.
4. If the meeting agenda is accepted, during the meeting, facility should be able to present the standard
references to justify their comments. TRBA shall forward such scenarios for internal committee review and
decision.
5. In case the facility is requesting for further analysis on JDC evaluations and committee decision, an appeal
request can be sent to DoH at quality@haad.ae
6. The appeal request shall include the facility license, region, head of the facility details and the Audit
representative details along with the details of audit concerns with supporting documents and references.
7. Additionally, as part of feedback process, a survey link is shared to the healthcare facilities to collect the
feedback on the audit process.
35
8. Complaints/Feedback tab is available on the webpage of TRBA. Any
concern or feedback can be shared by facilities using this option which shall automatically redirect the
complaints to DoH and TRBA Higher management.
1
APPENDIX
Appendix-I – The Tier System
Appendix-II- Scoring Weights & Examples
Appendix-III- Scoring Tables
2
APPENDIX-I
The Tier System
3
The Tier System
The Tier system is classified based on the annual volume of claims submission. Tiers are classified by facility types as
Tier H for Hospitals, Tier M for Centers/ Clinics, Tier D for exclusive Dental Centers (Services), Tier HC for Home Health
Care Centers, Tier RH for Rehabilitation Hospitals (Long Term Care Centers) and Tier SP for exclusive Self-Pay services.
Table 1
Tier
Billing Volume/Year
Claim Sample
Medical Centers
Tier 6-M
>=150,001
95
Tier 5-M
100,001 to 150,000
75
Tier 4-M
50,001 to 100,000
60
Tier 3-M
25,001 to 50,000
41
Tier 2-M
10,001 to 25,000
30
Tier 1-M
<=10,000
24
Table 2
Tier
Billing Volume/Year
Claim Sample
Home Health care
Tier 3-HC
>= 26,001
30
Tier 2-HC
15,001 to 26,000
25
Tier 1-HC
<=15,000
20
Table 3
Tier
Billing Volume/Year
Claim Sample
Hospitals
Tier 6-H
>=700,001
221
Tier 5-H
400,001 to 700,000
185
Tier 4-H
200,001 to 400,000
140
Tier 3-H
100,001 to 200,000
102
Tier 2-H
50,001 to 100,000
70
Tier 1-H
<=50,000
60
4
Table 4
Tier
Billing Volume/Year
Claim Sample
Rehabilitation
Hospitals
Tier 4-RH
>=50,001
35
Tier 3-RH
25,001 to 50,000
30
Tier 2-RH
10,001 to 25,000
25
Tier 1-RH
<=10,000
20
Table 5
Tier
Billing Volume/Year
Claim Sample
Dental
Tier 4-D
>=50,001
30
Tier 3-D
30,001 to 50,000
26
Tier 2-D
15,001 to 30,000
23
Tier 1-D
<=15,000
20
Table 6
Tier
Billing Volume/Year
Claim Sample
Self-Pay
Tier 4-SP
>=5,001
20
Tier 3-SP
1,001 to 5,000
18
Tier 2-SP
201 to 1,000
15
Tier 1-SP
1 to 200
10
Tier SP
No Submission- <1
10
5
APPENDIX-II
Scoring Weights & Examples
6
Scoring Weights and Examples
The Final JAWDA Data Certification Score will be a comprehensive score obtained as per the assigned scoring weights
for each domain - Claims Review Score, Clinical Coding Process Review Score, KPI Process Review Score and, KPI Data
Validation score for Hospitals, Home health Care, Long Term Care as applicable.
The Summary of scoring weights per the facility type is as shown below:
Table 1- Summary of scoring weights
Hospitals / Home Health Care/Long Term care /Rehabilitation Hospital
Scope
Weight
Claims Review Score
40
Clinical Coding Process Review Score
10
KPI Process Review Score
25
KPI Data Validation Score
25
Table 2- Summary of scoring weights – Centers/Clinics
Centers/Clinics /Exclusive Dental/Exclusive Self-Pay
Scope
Weight
Claims Review Score
80
Clinical Coding Process Review Score
20
7
Examples of Scoring per facility Type and settings as per applicable domain weights
Example1: Details of scoring for the medical centers and clinics will be as shown in the below table as an example: Table 3
Example2: Details of scoring for Home Health Care will be as shown in the below table as an example: Table 4
8
9
Example 3: Details of scoring for the Hospitals will include KPI Indicators validation along with Clinical Coding as shown in the
below table: Table 5
10
APPENDIX-III
Scoring Tables
11
Tables of Error Scoring for Claims Review (Revised)
Table 1: Error Scoring: Inpatient /Long Term Care (LTC) – Accuracy
ERROR SCORING TABLE FOR INPATIENT / LTC - ACCURACY ERRORS
Category-Score
Accuracy Error
Example and Explanation
1. Major Encounter type error-10 - BILLING RELATED
Major
10
Claim uploaded to wrong Encounter Type.
Claimed codes are uploaded to incorrect encounter type.
2. Moderate Per-Diem code error- 05
Moderate
5
Missing/ Incorrect - Per-Diem codes or service codes
or
Per-Diem codes or service codes added without
documentation
Missed to bill appropriate Per-Diem codes/service codes
OR
Billed Per-Diem codes/service codes are incorrect for the service
provided.
Billed Per-Diem codes/service codes added without supportive
documentation; (17-23 added without recovery room service)
Moderate
5
Other miscellaneous billing errors/ Incorrect units of
billing with Zero charges
Other miscellaneous billing errors like incorrect anesthesia units,
infusion or hydration units billed
CPT 36415 billed without performing within the facility or
CPT 36415 Venipuncture is not eligible to report as per guidelines
E&M AND PROCEDURE ACCURACY ERROR – CODING RELATED
3. Major Procedure Error-20
12
Major
20
Surgical procedure coded without documentation.
“31623 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,
when performed; with brushing or protected brushings” is coded when
there is no documentation to substantiate brushing. Also coding an add-
on code without a relevant primary procedure code.
Major
20
Incorrect surgical procedure code.
Claimed code does not match what is documented “EGD diagnostic
procedure done without specimen collection but coded EGD with
biopsy”.
Major
20
Missed to code surgical procedure code.
Surgical (Minor or Major) Procedure not coded when it is performed.
4. Major Evaluation and Management Error-15
Major
15
E & M code missing, high or in the wrong category; or
coded without documentation or coded with
insufficient documentation;
• Missed to code E&M code or E & M code does not meet the
documentation criteria. • Inpatient E & M codes are mandatory on all
records, assigned according to guidelines and rules, as of 1
st
January 2014.
If they are missing, in the wrong category, or are higher than warranted
by documentation, it shall be scored as an error (Please, see LTC below
for clarity)
• If LTC or a subtype must be claimed according the LTC Standard and use
the applicable service codes. There is an error if an additional Inpatient E
& M is assigned – (LTC and subtypes must be claimed through inpatient
encounter type.)
• If Rehab (or LTC) is claiming by DRG as Inpatient stay, then the scoring
rules for Inpatient applies.
5. Moderate Procedure Error-10
13
Moderate
10
Non-surgical procedure/medicine codes are coded
without documentation / Incorrect CPT code.
Ex: Non-surgical procedure/services like radiology, immunization,
injection, IV, respiratory services, ECG, etc., are coded without
documentation / Coded wrong CPT.
6. Minor Procedure Error-5
Minor
05
Procedures do not have corresponding diagnosis code
documentation;
Turbinectomy Procedure performed but there is no corresponding
documentation and diagnosis to support the procedure performed.
Minor
05
Unbundling of CPT codes.
Any CPT which is bundled into another procedure should not be billed
together.
DIAGNOSIS ACCURACY ERROR – CODING RELATED
7. Major Diagnosis Error-20
Major
20
Diagnosis coded without documentation or coding sign
& symptom INSTEAD of the diagnosis.
Code is not as per the documentation,
OR
Coded sign or symptom and not the documented diagnosis such as a
PDx- R30.0 Dysuria coded when documentation shows a PDx- N39.0:
Urinary tract infection NOS.
Major
20
Incorrect selection of principal diagnosis.
The “Incorrect selection of Principal Dx” - refers to a sequencing issue, not
a documentation issue. Both codes must be present and the wrong one
is selected as principal diagnosis, but the correct code must be listed.
Major
20
Missing relevant principal diagnosis.
Claim is not coded with principal diagnosis of the actual reason for patient
admission.
14
Major
20
Claimed code does not match documentation /
Incorrect diagnosis codes.
Coded diagnosis is not accurate to the available documentation. Ex:
Documented as GBS +ve and coded as O98.81X without current infection
affecting the pregnancy.
If the codes assigned are not within the correct Category, then it would
be a Major Error of “Claimed code doesn't match/Incorrect diagnosis
code". [Ex: Documented as Acute appendicitis (K35.80) but coded as
Chronic appendicitis (K36)]
8. Moderate diagnosis error-10
Moderate
10
Missing relevant secondary diagnosis specific to this
encounter or specific to performed procedure.
Missing required and/or pertinent secondary diagnosis which is relevant
to this encounter, including Chapter 21 codes. (i.e. ‘history of’ codes, BMI,
Smoking, place of occurrence, activity etc.,)– Examples; Patient has
coronary artery disease and history of CABG not coded; Or Patient
morbidly obese and BMI is not coded. If manifestation code is assigned
without underlying condition or relevant Chapter 21 codes are not
assigned.
And, all Complication and Co morbidities (CC) or Major Complication and
Co morbidities (MCC).
Moderate
10
Error of specificity in diagnosis code.
The “Error of specificity in diagnosis code” refers to coding within the
correct Category or Subcategory but not coding to the specificity
available in the documentation. (Ex: Acute Bronchitis due to RSV coded
as Acute Bronchitis unspecified-J20.9 instead of J20.5);
15
Moderate
10
Procedures orders do not have corresponding diagnosis
code.
Order for ECG, however, there is no diagnosis documentation to justify
the reason for order.
Moderate
10
Primary diagnosis doesn't have any relationship with
the chief complaint.
Ex: Patient came with epigastric pain, but primary diagnosis coded as
osteoarthritis knee.
9. Minor Diagnosis Error-5
Minor
05
Coding Signs & Symptoms / condition is integral to
Diagnosis additionally.
Coding additionally (not instead of) Signs & Symptoms that are associated
routinely with a disease process, unless otherwise instructed by the
classification - Ex: “K27.7 Chronic peptic ulcer of unspecified site without
mention of hemorrhage or perforation, with obstruction” is the Principal
diagnosis and a secondary symptom code is added “R10.13 Dyspepsia.
OR
Documented as osteoarthritis in knee and coded both ICD's M17.9 &
M19.90. Against coding guidelines.
16
Table 2: Error Scoring: Inpatient – Completeness
SCORING TABLE FOR INPATIENT – COMPLETENESS ERROR
Category-Score
Completeness Error
Example and Explanation
DIAGNOSIS AND PROCEDURE ERRORS
1. Major Diagnosis Error-15
Major
15
Does not code “Possible, Probable etc.”
Coding Guidelines specify that in an Inpatient setting, the documentation
of “possible’’, ‘’probable’’, “?” etc. are to be coded.
2. Moderate Diagnosis Error -10
Moderate
10
Missing additional diagnosis.
Missed to assign additional code, according to coding rules and
guidelines and available documentation.
3. Major Procedure Error-15
Major
15
Missing non-surgical procedure codes
Non-surgical procedure/service codes like IM, IV, CTG, ECG, Anesthesia
codes etc., not coded when it is documented.
4. Major E&M Error-20
Major
20
Low E&M Inpatient;
E & M are mandatory to be coded on every claim. If the E & M is lower
than the available documentation.
DOCUMENTATION ERRORS
5. Major Documentation Error-20
17
Major
20
Missing documentation or insufficient documentation to
code Initial or subsequent day evaluation and
Management
No or Insufficient documentation to code the lowest level E/M; example
99221
Major
20
Missing documentation details for Procedures/ Operative
reports
Physiotherapy- Details of modalities, site of application of modality,
time start and end, authentication etc.,
Procedures: Aseptic precautions, Technique/approach of procedure,
detailed procedure notes, closure technique, hemostasis, risks
encountered if any, post procedural complications if any.
Injection: Site, route, strength, dose, time, initials
Operative note: Date of procedure, Physicians, Type of Anesthesia, Pre-
op and Post Op Diagnosis, Technique of procedure, detailed procedure
note, closure technique, hemostasis, risks encountered if any, post
procedural complications if any.
6. Moderate Diagnosis Documentation Error-10
Moderate
10
Missing Narrative Diagnoses
Missed to narrate the complete diagnoses in the clinical final impression
by the treating physician;
6. Moderate Service Documentation Error-10
Moderate
10
Radiology/Diagnostic reports have no documentation of
indication for test, technique or approach of
procedure/views of radiological examination;
Indication for X-ray: Cough
Technique or approach: PA view
No. of Views: Single
18
Findings:
Impression: Pneumonic consolidation
Table 3: Error Scoring: Outpatient/ER/Day case – Accuracy
ERROR SCORING TABLE FOR OP, ER, DAY CASE – ACCURACY ERRORS
Category - Score
Accuracy Error
Example and Explanation
1. Major Encounter type error-10 (Billing Related Error)
Major
10
Claim uploaded to wrong Encounter Type.
Claimed codes are uploaded to incorrect encounter type.
2. Moderate Per-Diem code error-5 (Billing Related Error)
Moderate
5
Missing / Incorrect Per-Diem or Service Code;
Missed to bill appropriate Per-Diem codes whenever applicable.
OR
Billed Per-Diem code is incorrect to the care provided (i.e., Medical or
surgical) and hours of stay.
Moderate
5
Other miscellaneous billing errors.
Incorrect Date of service on the claim
CPT 36415 billed without performing within the facility; Or
CPT 36415 Venipuncture is not eligible to report as per adjudication
guidelines
E&M / PROCEDURE ERROR - ACCURACY
2. Major Evaluation and Management Error-20
19
Major
20
E&M code missing, high and/or in wrong category;
or coded without documentation or insufficient
documentation;
Missed E&M code (Follow-up E&M) or E & M code does not meet the
documentation criteria.
3. Major Procedure Error-20
Major
20
Surgical/Diagnostic procedure coded without
documentation.
“31623 Bronchoscopy, rigid or flexible, including fluoroscopic guidance,
when performed; with brushing or protected brushings” is coded when
there is no documentation of to substantiate brushing.
Major
20
Incorrect surgical procedure code/Claimed code
does not match what is documented
Claimed code does not match what is documented “31622 Bronchoscopy,
rigid or flexible, including fluoroscopic guidance, when performed;
diagnostic, with cell washing, when performed” is on the record and
documentation and 31623 are coded. This can be either first-listed or
secondary.
4. Moderate Procedure Error-10
Moderate
10
Missed to code surgical procedure code.
Procedure not coded when it is performed. Documented as Simple Repair
leg, but missed to code CPT 12001
Moderate
10
E&M code is inclusive in procedure code or
procedure is inclusive in E&M.
Encounter only for injection, hence E&M should not be billed separately
without physician intervention. Follow coding guidelines for “distinct &/or
separate service. Example: A distinct E & M is coded in addition to initial
cast application. Wound dressing inclusive of E/M
Moderate
10
Non-surgical procedure/medicine procedure coded
without documentation / Coded with Incorrect CPT
code.
Ex: Non-surgical procedure/services like radiology, immunization, injection,
IV, respiratory services, ECG, etc., are coded without documentation /
Coded wrong CPT.
20
5. Minor Procedure Error-5
Minor
05
Unbundling of CPT codes. Minor procedure integral
to other procedure.
Any CPT which is bundled into another procedure should not be billed
together.
DIAGNOSIS ACCURACY ERROR – CODING RELATED
6. Major Diagnosis Error-15
Major
15
Diagnosis coded without documentation or coding
signs & symptoms INSTEAD of the diagnosis.
Diagnosis coded without documentation in the claim
OR
documentation does not support the billed code.
OR
Code is a documented sign or symptom and not the documented diagnosis
such as a PDx- R30.0 Dysuria coded when documentation shows a PDx-
N39.0: Urinary tract infection NOS.
Major
15
Claimed code does not match documentation /
Incorrect diagnosis codes.
The code which is on the Claim does not match what is documented and/or
coded.
Major
15
Coding Possible, Probable, suggestive, likely or
questionable diagnosis.
Coding Guidelines specify that in an Outpatient setting, the documentation
of “possible’’, ‘’probable’’, “?” etc. are not to be coded.
7. Moderate Diagnosis Error-10
Moderate
10
Missing relevant primary or secondary diagnosis
specific to this encounter.
Missing required and/or pertinent secondary diagnosis which is relevant to
this encounter,
including Chapter 21 codes. (i.e., ‘history of’ codes, BMI, Smoking, place of
occurrence, activity etc.,)– Examples are; Patient has coronary artery
21
disease and history of CABG not coded, Or Patient morbidly obese and BMI
are not coded. Also, if manifestation code is assigned without underlying
condition.
Or relevant Chapter 21 codes are not assigned.
Moderate
10
Coded condition is integral in another condition or
Code (specific or non-specific or other)
Documented as osteoarthritis in knee and coded both ICD's M17.9 &
M19.90. Against coding guidelines.
Moderate
10
Error of specificity in diagnosis code.
The “Error of specificity in diagnosis code” refers to coding within the
correct Category or Subcategory but not coding to the specificity available
in the documentation. (Ex: Acute Bronchitis due to RSV coded as Acute
Bronchitis unspecified-J20.9 instead of J20.5); If the codes assigned are not
within the correct Category, then it would be a Major Error of “Claimed
code doesn't match/Incorrect diagnosis code". [Ex: Documented as Acute
appendicitis (K35.80) but coded as Chronic appendicitis (K36)]
Moderate
10
Procedures or Prescription orders do not have
corresponding diagnosis code/Diagnosis
Documentation
Principal diagnosis – J45.909 Unspecified Asthma
Principal procedure - 36660 Catheterization, umbilical artery, newborn, for
diagnosis / therapy.
Moderate
10
Primary or Principal diagnosis coded is not relevant
to the chief complaint or doesn't have any
relationship with the chief complaint.
Ex: Patient came with epigastric pain, but primary diagnosis coded as
osteoarthritis knee. This is not to be confused with sequencing error. In
this case, there will not be any final diagnosis related to chief complaint in
secondary or tertiary or other positions.
Ex: Chief complaint: Cough, joint tenderness documented in PE, Final
diagnosis is osteoarthritis
22
8. Minor Diagnosis Error-5
Minor
05
Incorrect sequencing of diagnosis.
This is strictly a sequencing issue, not a documentation issue. Both/all
codes are present; however, the wrong code is selected as principal
diagnosis. If another code (incorrect) is listed, then it would be a Major
Error of “Diagnosis coded without documentation”.
Minor
05
Coding Signs & Symptoms to support for
Prescriptions and labs or Coding Signs & Symptoms
integral to Diagnosis additionally
Coding additionally (not instead of) Signs & Symptoms that are associated
routinely with a disease process, unless otherwise instructed by the
classification - Example: “K27.7 Chronic peptic ulcer of unspecified site
without mention of hemorrhage or
perforation, with obstruction” is the Principal diagnosis and a secondary
symptom code is added “R10.13 Dyspepsia.
23
Table 4: Error Scoring: Coding Error List Outpatient/ER/Day Case – Completeness
SCORING TABLE FOR OP, ER, DAY CASE – COMPLETENESS ERRORS
Category-Score
Completeness Error
Example and Explanation
DIAGNOSIS AND PROCEDURE ERRORS
1. Major Diagnosis Error - 10
Major
10
Missing additional diagnoses code(s);
Missed to assign additional code, according to coding rules and
guidelines and available documentation.
2. Major Evaluation and Management Error-10
Major
10
Coding Low E & M
E&M level coded low when the documentation is meeting to code
higher level.
3. Major Procedure Error-10
Major
10
Missing non-surgical procedure code or missing Service
codes
Non-surgical procedure/service codes like IM, IV, NEB, vaccination,
anesthesia codes etc., not coded when it is documented. Ex: Missed to
code dressing 51-02 when documented.
CLINICAL DOCUMENTATION ERRORS
4. Major Documentation Errors - 15
Major
15
Missing documentation details for Procedures
Physiotherapy- Details of modalities, site of application of modality,
time start and end, authentication etc.,
24
Procedures: Aseptic precautions, Technique/approach of procedure,
detailed procedure notes, closure technique, hemostasis, risks
encountered if any, post procedural complications if any.
Injection: Site, route, strength, dose, start/end times, initials
Operative note: Date of procedure, Physicians, Type of Anesthesia,
Pre-op and Post Op Diagnosis, Technique of procedure, detailed
procedure note, closure technique, hemostasis, risks encountered if
any, post procedural complications if any.
Major
15
Missing Narrative Diagnoses
Missed to narrate the complete diagnoses in the clinical final impression
by the treating physician;
5. Moderate Documentation Errors - 10
Moderate
10
Systems Review and Physical Examination is contrary to
documented and coded conditions.
Diagnosed with Acute Tonsillitis, ENT examination shows normal;
Moderate
10
Relevant system examination is missing in the
document.
Dermatitis as Final Diagnosis, examination of Skin/Integumentary
system is Completely missing.
Moderate
10
Extensive template documentation of physical
examination and review of systems. Not updated as per
the relevancy to the visit conditions.
Documentation of 12 systems for dermatitis
Moderate
10
Radiology/Diagnostic reports have no documentation of
indication for test, technique or approach of
procedure/views of radiological examination
Indication for X-ray: Cough
Technique or approach: PA view
No. of Views: Single
25
Findings:
Impression: Pneumonic consolidation
26
Table 5 Error Scoring: Home Health Care – Accuracy
SCORING TABLE FOR HOME CARE – ACCURACY ERRORS
Category-Score
Accuracy Error
Example and Explanation
1. Major Encounter Type -10
Major
10
Claim uploaded to wrong Encounter Type
Claimed codes are uploaded to incorrect encounter type
Major
10
Other Billing Errors
Ex: Claim submitted with incorrect encounter date.
Claim submitted with incorrect Quantity of each CPT & Service codes.
PROCEDURES ACCURACY ERRORS
2. Major Procedure Error - 20
Major
20
Procedure coded without documentation
“99507 Home visit for care and maintenance of catheter” is coded when
there is no documentation to substantiate PEG tube care.
“98960 Education & Training for Patient self-management” is coded when
there is no documentation to substantiate timing.
3. Major Home Care Evaluation & Management Error - 15
Major
15
E&M level high and/or in wrong category
E & M code does not meet the documentation criteria.
4. Moderate Procedure Error for Physiotherapy Evaluation-10
Moderate
10
Physiotherapy evaluation / services coded without
documentation
“97002 Physical therapy re-evaluation” is coded
when there is no documentation to substantiate
Physiotherapy assessment”
“97110 coded without documentation”
5. Moderate Procedure Error -10
27
Moderate
10
Incorrect procedure code
Claimed code does not match what is documented.
“Documented as Sub cutaneous insulin injection but coded for IM injection
99506 procedure code” etc.,
6. Minor Procedure Error -05
Minor
5
Unbundling of CPT codes.
Any CPT which is bundled into another procedure should not be billed
together.
DIAGNOSIS ACCURACY ERRORS
6. Major Diagnosis Error - 15
Major
15
Diagnosis coded without documentation.
Coded diagnosis is not per the documentation.
Major
15
Claimed code does not match documentation.
The code which is on the Claim does not match what is documented and/or
coded.
Major
15
Coding Possible, Probable or questionable diagnosis (see
Coding Guidelines) Coding Possible, Probable or questionable
diagnosis (see Coding Guidelines)
Coding Guidelines specify that outpatient setting, the documentation of
“possible’’, ‘’probable’’, “?” etc. are not to be coded.
7. Moderate Diagnosis Error-10
Moderate
10
Coding Signs & Symptoms integral to Diagnosis additionally OR
Coded condition is integral to another condition additionally
Coding additionally (not instead of) Signs & Symptoms that are associated
routinely with a disease process, unless otherwise instructed by the
classification - Example: “K27.7 Chronic peptic ulcer of unspecified site
without mention of hemorrhage or perforation, with obstruction” is the
Principal diagnosis and a secondary symptom code is added “R10.13
Dyspepsia
28
Diagnosis Hemiplegia is integral to condition hemiplegia due to CVA.
Diagnosis unspecific Hyperlipidemia is integral to mixed hyperlipidemia.
Moderate
10
Error of specificity in diagnosis code
The “Error of specificity in diagnosis code” refers to coding within the
correct Category or Subcategory but not coding to the specificity available
in the documentation. If the codes assigned are not within the correct
Category/Sub category, then it would be a Major Error of “Diagnosis coded
without documentation”. The example would be the documentation
showing the site as the toe and the code assigned is the foot when greater
specificity is available.
Moderate
10
Missing relevant diagnosis specific to this encounter
Missing required and/or pertinent secondary diagnosis which is relevant to
this encounter, including Chapter 21 codes. (i.e., ‘history of’ codes, BMI,
Smoking, place of occurrence, activity etc.,)– Examples are; Patient has
coronary artery disease and history of CABG not coded, Or Patient morbidly
obese and BMI are not coded. Also, if manifestation code is assigned
without underlying condition. Or relevant Chapter 21 codes are not
assigned.
8. Minor Diagnosis Error-5
Minor
05
Incorrect Selection of Primary Diagnosis
Ensure that the diagnosis is the one most related to the patient’s current
plan of care, is the chief reason home care is needed, and is the most acute
condition requiring the most intensive skilled services (if more than one
diagnosis is treated concurrently).
29
Minor
05
Acute conditions are not codable;
Resolved and/or History conditions are not codable
Acute diagnosis currently not on medication cannot be coded in home care
set up. Resolved diagnosis cannot be coded in home care set up. Ex-Cannot
code history of CVA when patient is still having hemiplegia due to late effect
of CVA. Documented as laryngeal carcinoma, status post laryngectomy,
hence cannot code the diagnosis malignant neoplasm of larynx.
Minor
05
Incorrect sequencing of diagnosis
This is strictly a sequencing issue, not a documentation issue. Both/all codes
are present; however, the wrong code is selected as principal diagnosis. If
another code (incorrect) is listed, then it would be a Major Error of
“Diagnosis coded without documentation”.
30
Table 6: Error Scoring: Home Health Care – Completeness
SCORING TABLE FOR HOME CARE – COMPLETENESS ERRORS
Category-Score
Completeness Error
Example and Explanation
1. Major Procedure Error - 20
Major
20
Missing Procedure Codes
Documentation shows a procedure is performed and the code is not
assigned.
2. Major E&M Error - 10
Major
10
Coding Low E & M / Missing E & M
Missed to code E&M when evaluation is performed
3. Moderate Procedure Home Physiotherapy - 10
Moderate
10
Physiotherapy coded with insufficient documentation.
Insufficient documentation may be: Missing detail documentation of each
Physiotherapy Modalities. Start time and/or end time of each
Physiotherapy modalities is not documented
4. Moderate Procedure Home Nurse visits - 10
Moderate
10
Nursing procedure coded from insufficient documentation.
Insufficient documentation found for the claim code may be:
• Missing detail documentation of each Home visit services.
• Missing detail documentation of pattern of care (Nursing duration, etc..)
5. Minor Physiotherapy Evaluation - 5
Minor
5
Missing Physiotherapy Evaluation or re-evaluation code
Documentation shows physiotherapy assessment is performed but the
code is not assigned.
DIAGNOSIS COMPLETENESS ERRORS
6. Major Diagnosis Error - 10
31
Major
10
Missing additional diagnoses code(s)
Missed to assign additional code, according to coding rules and guidelines
and available documentation.
DOCUMENTATION COMPLETENESS ERRORS
7. Major Documentation Error - 20
Major
20
Missing Narrative diagnoses
Missed to narrate the complete diagnoses in the clinical final impression
by the treating physician;
8. Moderate Documentation Error - 10
Moderate
10
Systems Review and Physical Examination is contrary to
documented and coded conditions.
Diagnosed with Pressure Ulcer, Integumentary examination shows normal;
9. Minor Documentation Error - 5
Minor
5
Relevant system examination is missing in the document.
Dermatitis as Final Diagnosis, examination of Skin/Integumentary system
is Completely missing.
Table 7: Error Scoring: Dental Setting – Accuracy
SCORING TABLE FOR DENTAL CARE – ACCURACY ERRORS
Category - Score
Accuracy
Example and/ or Explanation
1. Major Encounter Type -10
Major
10
10
Claim uploaded to wrong Encounter Type
Other miscellaneous billing errors
Claimed codes are uploaded to incorrect encounter type
Incorrect Date of service on the claim Or Incorrect units of Additional or
add-on non-surgical procedure codes
32
PROCEDURES ACCURACY ERRORS
2. Major Procedure Error – 20
Major
20
Procedure coded without documentation
''21111 Restorations, Amalgam, Non-Bonded, Primary Teeth One surface
is coded'' when there is no documentation to support any restoration.
3. Major Dental Care Examination Error - 25
Major
25
Examination without documentation / Incorrect Examination
Code
''01201 Examination and Diagnosis, Limited, Oral, New Patient'' is coded''
when there is no documentation to support any examination OR an
Incorrect Dental Examination Code is coded to the available
documentation.
4. Moderate Procedure Error -10
Moderate
10
Incorrect procedure code / Claimed Procedure does not match
what is documented / Incorrect tooth Number/Missing Tooth
Number;
The Procedure code or tooth number for the procedure, which is on the
Claim does not match what is documented and/or coded.
Missed to document the Tooth number;
Moderate
10
An additional procedure/Minor procedure code which is
inclusive in the Examination code;
A related minor procedure or examination is included in major procedure
or examination performed on the same visit.
DIAGNOSIS ACCURACY ERRORS
5. Major Diagnosis Error – 20
Major
20
Diagnosis coded without documentation or coding sign
symptom INSTEAD of the diagnosis;
Code is not per the documentation, e.g. documentation does not support
the code. OR Code is a documented sign or symptom and not the
documented diagnosis such as a PDx- K08.89: Tooth pain coded when
documentation shows a PDx- K04.7: Dental Abscess
33
Major
20
Claimed code does not match documentation;
The code which is on the Claim does not match what is documented and/or
coded.
Major
20
Coding Possible, rule out, Suspected, Probable or questionable
diagnosis;
Coding Guidelines specify that in an Outpatient setting, the documentation
of “possible’’, ‘’probable’’, “?” etc. are not to be coded. Not Applicable in
Inpatient setting.
6. Moderate Diagnosis Error-10
Moderate
10
Dental Procedures do not have corresponding diagnosis code;
Any dental procedure code which is not supported by a related dental
diagnosis.
Moderate
10
Missing relevant primary / secondary diagnosis specific to this
encounter;
Missing required and/or pertinent secondary diagnosis which is relevant to
this encounter. Examples are; Patient Encounter is for dental examination
and cleaning with abnormal findings, abnormal findings were not coded.
Also, if manifestation code is assigned without underlying condition.
Moderate
10
Coding Signs & Symptoms integral to Diagnosis additionally;
Coding additionally (not instead of) Signs & Symptoms that are associated
routinely with a disease process, unless otherwise instructed by the
classification.
Example: “K04.7, Periapical abscess without sinus'' is the Principal
diagnosis and a secondary symptom code is added “K08.89 Toothache.
Moderate
10
Error of specificity in diagnosis code;
The “Error of specificity in diagnosis code” refers to coding within the
correct Category or Subcategory but not coding to the specificity or
Incorrect specificity as per the availability in the documentation. The
example would be the documentation showing the dental caries into pulp
and unspecified dental caries, when greater specificity is available.
34
7. Minor Diagnosis Error – 5
Minor
05
Incorrect sequencing of diagnosis;
This is strictly a sequencing issue, not a documentation issue. Both/all
codes are present; however, the wrong code is selected as principal
diagnosis.
35
Table 8: Error Scoring: Dental Setting – Completeness
SCORING TABLE FOR DENTAL CARE – COMPLETENESS ERRORS
Category-Score
Accuracy
Example and/or Explanation
PROCEDURE AND EXAMINATION ERROR
1. Major Procedure Error - 20
Major
20
Missing Dental Procedure Code;
Documentation shows a procedure is performed, which is significant and
separate from other procedure codes and the code is not assigned.
2. Major Examination Error - 20
Major
20
Missing Dental Examination;
Documentation shows a dental examination is performed, which is
significant and separate, from other procedure codes and the code is not
assigned.
DIAGNOSIS COMPLETENESS ERROR
3. Major Diagnosis Error - 20
Major
20
Missing Narrative Diagnoses;
Missed to narrate the complete diagnoses in the clinical final impression
by the treating physician;
DOCUMENTATION COMPLETENESS ERROR
4. Major Documentation Error - 10
Major
10
Missing documentation details for Procedures;
Procedures: Aseptic precautions, Technique/approach of procedure,
detailed procedure note, hemostasis, risks encountered if any, post
procedural complications if any, Timing documentation for time-based
codes
36
Major
10
Missing documentation details for Examinations;
Or
Relevant dental examination is missing, or documented
examination is contradicting coded conditions
Examinations: Dental completeness of documentation like (Chief
complaint, dental examination intra oral and or extra oral & its types
(primary, mixed, permanent dentition not based on age criteria), charting,
dental history, past medical history, allergy, pre-& post instructions,
treatment plan, follow ups, prescription etc.)
Follow-up visit – Chief complaint should correlate with the staged
procedure/Reason for visit; (e.g. – RCT)
Plaque & Gingivitis as Final Diagnosis, examination of Intraoral is
Completely missing.
Diagnosed with Periapical Abscess, Gingivitis. Dental Intraoral examination
shows normal;
Moderate
10
Missing additional diagnoses
There is not complete and full code assignment(s), according to coding
rules and guidelines and available documentation
Moderate
10
Radiology/Diagnostic reports have no documentation of
indication for test, technique or approach of procedure/views
of radiological examination & Interpretation of the X-ray;
Indication for X-ray: Caries/Pulpitis
Technique or approach: Periapical view
No. of Views: Single
Findings:
Impression: Dental caries penetrating the pulp
Missed to document the interpretation in the Dental clinical visit;
Histopathology/Test/Analysis documentation;
