Function in a fully accountable role with respect to ensuring the overall quality of inpatient and outpatient coding and the constant improvement thereof. Follows the standards of ethical coding as published by AHIMA.
Minimum Qualifications
Work Experience
Previous coding experience in the area of ICD, CPT-4, and DRG methodology preferred.
Education
Completion of a Coding program or independent study course required.
A.S. Degree in Health Information Technology or B.S. Degree in Health Records Administration preferred.
Certifications/Licensure
RHIT, RHIA, CCS, CCA, CPC, COC required within 6 months from hire or placement.
Job Specific Performance Standards
The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.
Responsible for all inpatient and outpatient coding functions, ensuring that system goals and objectives are met.
Ensure that accurate and complete inpatient and outpatient coding is performed and used for measuring and reporting physician and hospital outcomes.
Ensure that accurate and complete outpatient coding is performed to be used for reporting agencies as related to outpatient ancillary coding. Ensure that accurate and complete inpatient coding is performed to be used in core measures, meaningful use, value based purchasing, and others as needs arise.
Maintain quality and quantity standards of work performed set by management team.
Participate in the development of inpatient/outpatient coding policies and procedures.
Participate in quality improvement activities within coding unit and HIM department.
Analyze data produced from standards and reports and implement corrective actions plans if necessary.
Maintain a 97% accuracy rate on performance improvement audits. Maintain the performance goals as established for the coding specialist.
Become proficient with ICD-10.
Complete training and education programs.
When requested, participate in educational/compliance programs for physicians, nursing, and other health professionals who document in the medical record. Promote teamwork between coders, physician office staff, physicians, CDI specialist and other ancillary departments.
Provide assistance for computer system implementations.
Become proficient in the use of 3M, Meditech, and any other acquired system/software.
Integrate the systems into processes and procedures.
Complete all applicable education and training. Suggest improvements and enhancements to the computer systems to ensure and/or increase efficiency.
Work with other coders, senior coding specialist, coding managers, CDI specialist in a team environment.
Discuss documentation and coding scenarios with fellow team mates, senior coding specialist, coding manager, CDI team.
Resolve DRG mismatches and discuss physician queries with CDI specialist.
Communicate to management any barriers, conflicts, or coding/documentation quality issues in a timely manner.
Assist in the training of new coding specialist.
Serve as a resource to other coding specialist to ensure a standardized coding process.
Work with CDI specialist to ensure documentation is appropriate for accurate, complete, and compliant coding. Work with the Corporate Compliance and Audit & Appeal departments to ensure documentation is appropriate for accurate and complete coding.
Maintain extensive, up to date knowledge of Local and National Coverage Determinations and other CMS transmittals as related to outpatient coding.
- Respond to 3M edits in relation to failed medical necessity edits. Review policy within 3M reference package, re-review record to ensure accurate coding.
Maintain extensive, up to date knowledge of coding and demonstrate knowledge of the documentation requirements and coding guidelines in accordance with Coding Clinic.
Attend all education sessions coordinated by the management team. Review all published Coding Clinics to maintain up to date coding guidance.
Performs coding and abstracting processes according to the Med Center Health policies and procedures as established by the management team.
Identify records for coding based on patient type (inpatient vs. outpatient).
Review the medical record to determine whether existing documentation supports final coding or if additional clarification is needed.
Inpatient team: using 3M encoder, assign the DRG and APR-DRG, including the severity of illness and risk of mortality scores.
Inpatient team: Assign present on admission (POA) indicators for all diagnoses codes based on the documentation at the time of admission.
Track reasons for coding delays within Meditech for accounts that require additional documentation. Work with HIM held bills coordinators.
Communicate with CDI specialist regarding clarification needed for achieving the most accurate and complete documentation to ensure compliance.
Verify that any requested clarification has been documented in the medical record prior to final coding.
Inpatient team: Track CDI related activities and transactions in ClinTrac.
Ensure that all accounts are final coded in a timely manner. Assist in the monitoring of unbilled accounts.
Abstract all required data fields within Meditech according to standardized policies. Adheres to Med Center Health and Health Information Management Department policies and procedures.
Serve as a resource for Med Center Health department managers, staff, physicians and administration to obtain information on accurate and ethical documentation standards, guidelines, and regulatory requirements.
Inpatient team: serve as members of the CDI Task Force and participate in monthly meetings.
Serve as ad-hoc members and participate in other interdisciplinary meetings within the facility related to coding and compliance. Participate in quality improvement projects within unit, department, and Med Center Health.
Med Center Health
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