Senior Coding Specialist-Outpt

Position Purpose

The purpose of this position is to correctly assign ICD-10-CM diagnostic/procedural CPT codes on clinical encounters in accordance with regulatory and CMS Official Guidelines for coding and reporting to ensure accurate reimbursement.

Nature and Scope

Incumbent provides advanced Clinical outpatient coding support through the Health Information Management department and works in conjunction with the Health Information Management leadership to complete all applicable coding assignments that can include Laboratory, Radiology, Emergency Department, Same Day Surgery, and Observation encounters. For compliance, this position must adhere to CMS’ Official Guidelines for Coding and Reporting. Advanced outpatient coding staff must also have experience in one or more of these specialty outpatient areas including but not limited to; Recurring Wound Care, Injection Infusion Charging, Home Health, Hospice, Specialty Hospital Outpatient Departments and Pain Management.

Job responsibilities include the accurate assignment of ICD-10-CM diagnostic codes by proficiently translating diagnostic statements, physician orders, and other pertinent documentation; leading to coding accuracy and abstracting of pertinent data elements from documentation provided to report and code for reimbursement.

This position may also be responsible for identifying appropriate charges based on documentation and coding guidelines. When documentation or a valid order is incomplete, vague, ambiguous, or missing it is the responsibility of incumbent to work in conjunction with HIM staff to utilize the appropriate physician clarification process to obtain additional information that provides a codeable sign, symptom, or diagnosis and/or physician order. Other responsibilities include:

Incumbent will also be responsible for addressing RAC and related payer denials and reviews, Do Not Bill (DNB) Reports, and Claim Edits. Coding of highly complex medical records as well as medical record review. This class differs from the intermediate Coding Reimbursement Specialist in that addressing reviews and focused auditing when needed is distinctive; knowledge and skill level is greater. Supervision is not a responsibility of this position, however technical guidance and acting in a mentoring educational role is expected when appropriate.

• Addresses appeals and review documentation needed for insurance denials to facilitate expedient resolution and reimbursement.

• Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.

• Identifies and analyzes patterns in possible coding errors or other trends to report to Coding Leadership, Coding Leads and/or Coding Auditor.

• Ensures that all factors necessary for assigning accurate DRG are present, and that related diagnoses are ranked properly.

• Assign accurate present on admission indicators.

• Provides information and responds to inquiries regarding medical documentation and DRG’s to CDI staff including Utilization and Quality Assurance Departments when needed.

• Knowledge of discharge disposition and reimbursement outcomes.

This position must consistently meet or exceed productivity and quality standards as defined by department Leadership.

KNOWLEDGE, SKILLS & ABILITIES

• Knowledge of Anatomy and Physiology, Disease Pathology, and Medical Terminology.

• Knowledge of basic coding conventions and use of coding nomenclature consistent with CMS Official Guidelines for Coding and Reporting ICD-10-CM coding.

• Accurate translation of written diagnostic descriptions to appropriately and accurately assign ICD-10- CM diagnostic codes to obtain optimal reimbursement from all payer types, including Medicare/Medicaid, and private insurance payers.

• Ability to navigate the Electronic Medical Record to identify appropriate documentation for coding/billing in support of submitted department charges.

• Knowledge of clinical content standards.

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred