Ensures data integrity for ICD-9-CM, ICD-10-CM/PCS, and CPT coding by adding an extra layer of concurrent and retrospective quality and compliance monitoring. Identifies coding trends and opportunities for improvement in coding practices. Serve as a coding resource for the organization. Reviews and resolves billing, coding, and claim edit issues and errors to produce 'clean' claims. Provides feedback and education to HIM and CCHMC staff regarding identified trends in coding, billing, and claim edit issues. Creates routine and ad hoc reports and presentations.
Identify issues, review auditing trends and coded data to identify data quality concerns and opportunities for education. Conduct quality reviews to determine the accuracy of ICD-9-CM, ICD-10-PCS, and CPT-4 code assignment, as well as modifier assignment, DRG computation, Present on Admission indicators, abstracted data, and other coding/billing practices as directed. Review coding errors with coding staff, and prepare reports for organizational review as appropriate. Calculate quality metrics on a regular basis and prepare quality reports for area/departmental review. Participate in Quality Assessment and Performance Improvement functions for the coding area.
Monitor assigned HIM work queues in EPIC and completes outstanding coding issues identified in work queues in a timely manner. Assist HIM Coding Management with coordination of coding workflows in order to meet bill drop requirements. Assist HIM Coding Management in entering coding productivity data. Provide coding support as necessary to meet DNFB (discharge not final billed) goals by assigning high quality ICD-9-CM, ICD-10-CM/PCS, and CPT codes and modifiers, utilizing the 3M encoding and abstracting software, and coding manuals.
Provide training and education to HIM Coding Specialists in coding and reimbursement systems, HIM and organizational applications, internal and external coding policies and procedures, and other items as appropriate. Perform and oversee training for new and/or transitioning coding staff in ICD-9-CM, ICD-10-CM/PCS, and CPT coding conventions, as well as inpatient and outpatient payment methodologies. Provide staff in-services as necessary on topics approved by management. Serve as a resource for the coding staff on coding, documentation, billing, and/or system issues. Serve as a coding resource for other CCHMC departments and external customers. Actively participate in coding, department, data quality meetings. Assist staff and management in researching specific coding issues encountered to determine the appropriate code assignment and provide subsequent education to staff. Serve as a liaison to external departments regarding coding issues including interim coding and ongoing open account procedural coding.
Analyze gaps in clinical terminologies and medical vocabularies as compared to documented data, communicate necessary clinical documentation improvements to medical staff utilizing standardized coding queries, monitor and followup on queried documentation, and report findings to Coding Management.
Manage information from 3M database by maintain data tables. Demonstrate the ability to utilize 3M reporting tools to produce accurate reports as necessary to support coding/quality review processes, and fulfill other reporting requests as necessary. Work in conjunction with Information Systems Department staff to provide testing capabilities for coding related software and to problem solve issues related to current coding systems.
·Claim Edit Management
Review and reconcile NCCI, LCD, Medical Necessity and other claim edit errors identified. Trend edit error issues and communicate findings to HIM Management, Coding Staff, and other CCHMC departments and divisions, as appropriate. Provide education to HIM Coding Staff regarding NCCI and LCD edits, medical necessity, modifier assignment, and other related issues.
Skills & Competencies
Using time efficiently and productively; prioritizing multiple tasks properly to meet deadlines; recognizing time constraints and adjusting work schedule to address them.
·Customer Service - Basic
Ability to respond to basic customer requests with patience and enthusiasm; understands the needs of customers and escalates issues when appropriate
Understanding and showing respect and appreciation for the uniqueness of all individuals; leveraging differences in others' perspectives and ideas; appreciating cultural differences and adjusting one's approach to successfully integrate with others who are different from oneself
·Computer Hardware - Basic
Basic understanding of hardware usage and troubleshooting
·Independence and Teamwork
Ability to work autonomously, with independent judgment, as well as in a collaborative team environment.
Strong organizational and project management skills to handle projects independently.
Ability to independently work through details of a problem to reach a positive solution
Excellent verbal, written and/or interpersonal communication skills
Expert knowledge of ICD9, ICD10, and CPT-4 coding classification systems and guidelines, Knowledgeable in CMS, Ohio Medicaid, and other regulatory agency rules and regulations related to coding and reimbursement.
Proficiency in basic computer applications such as Microsoft Office, email and internet. Ability to compile and display data in easy-to-understand and ready-to-use formats using formulas, mathematics, graphs, charts and tables.
·Adv. Coding & Billing Knwldg:
Expert-level knowledge of ICD and CPT coding systems, CMS and state Medicaid rules and regulations, and commercial payer guidelines relating to documentation, coding and billing for health care services. Strong analytical knowledge and abilities of best coding, billing, and documentation practices.
Working cooperatively with others to achieve group goals; proactively adjusting one's style and efforts to complement those of others on the team; being pleasant, agreeable, and easy to work with; valuing group success as much or more than individual success.
Locating and gathering relevant information; recognizing and working to eliminate important gaps in existing information; determining the value of the information, synthesizing and organizing information to get a better understanding of a problem.
·Associate's Degree in a related field
·Registered Health Information Technician OR Registered Health Information Administrator OR Certified Coding Specialist
·Successful completion of hospital's administrated Coding Competency test
·5 years coding exp. in all aspects of ICD-9-CM, ICD-10-CM/PCS, CPT-4 coding & peds coding Preferred:
·Experience managing claim edits, including NCCI and LCD edits.
·Experience in all aspects of pediatric ICD-9-CM/PCS and CPT-4 coding.
·Experience performing quality reviews and education