Under the Direction of the Coding Manager, performs/facilitates departmental, interdepartmental and external coding audits to ensure quality completeness and accuracy of coding; compliance with Federal and State Regulations; and appropriate reporting. Provides education based on audit findings. Has thorough knowledge of Acute Care Facility Federal and State reporting guidelines, modifiers, sequencing rules, and the NCCI (National Correct Coding Initiative) edits, Official Guidelines for Coding and Reporting for ICD-10-CM, ICD-10-PCS, CPT-4 coding conventions, DRG and APC payment classifications and Medicare Conditions of Participation.
- Serves as subject matter expert on hospital performance improvement committees
- Response to coding questions from outside departments and provides coding references and guidelines
- Performs retrospective and concurrent audits to ensure coding accuracy and proper reporting
- Performs daily focused coding pre-bill reviews using coding compliance software
- Daily reviews are completed in a timely manner and meet department productivity guidelines
- Identifies documentation discrepancies in support of services billed including ICD10/CPT/HCPCS and other third party payer codes, DRG assignment, APC code assignment, medical necessity of services and reimbursement overpayments and underpayments.
- Demonstrates the ability to analyze coded data to identify areas of risk and provide suggestions for correction action
- Works closely with HIM Director/Coding Manager to develop internal and external audit plans
- Facilitates quarterly external audits
- Prepares and presents reports for pre-bill, and retrospective coding audits
- Serves as liaison between Coding and CDI teams related to appropriate coding queries and documentation concepts
- Develops/delivers education sessions to Hospital Departments, Coders, CDI and physicians related to audit findings
- Reports any compliance and/or risk issues to the compliance department. Provides suggestions on process improvement.
- Performs other duties as assigned.
Education, Training, and Experience:
- Bachelor’s degree or equivalent education/experience
- 8 – 10 Years of hands-on Inpatient/DRG and Outpatient coding, auditing, and related work.
- CCS credential.
- Clinical Documentation Improvement experience, credential.
Skills or Other Qualifications:
- Must have strong knowledge of CMS Conditions of Participation, Medicare and Medi-Cal hospital documentation requirements and Official Coding Guidelines, ICD-10/CPT/HCPCS/DRG coding rules, acute care hospital facility charge capture and reimbursement methodologies, including DRG, APC, CPT, ICD, HCPCSand HCPCS.
- Advanced skills and experience in the following areas: DRG/MS-DRG, APC, ICD/HCPCS/CPT, APR DRGs, Clinical Documentation Improvement and medical necessity determinations.
- Requires solid oral and written communication skills, attention to detail, professional demeanor, and appearance.
Position Reports to Director, HIM Services