POSITION SUMMARY
This position is responsible for the interpretation of clinical documentation completed by the health care team for the health record(s) and for quality assurance in the alignment of clinical documentation and billing codes. Works with medical staff and quality management staff to correctly align diagnosis documentation and billing coding to improve the quality of clinical documentation and correctness of billing codes prior to claim submission to third party payers; to identify possible opportunities for improvement of clinical documentation and accurate MS-DRG, Ambulatory Payment Classification (APC) or ICD-9 assignments on health records. Provides guidance and expertise in the interpretation of, and adherence to, the rules and regulations for documentation.

CORE FUNCTIONS
1. Provides coding and guidance for non-standard billing. Demonstrates extensive knowledge of clinical documentation and its impact on reimbursement under Medicare Severity Adjusted System (MS-DRG), and Ambulatory Payment Classification (APC) or utilized operational systems Provides explanatory and reference information to internal and external customers regarding clinical documentation which may require researching authoritative reference information from a variety of sources.

2. Reviews medical records. Performs a “Second Look” at clinical documentation to ensure that clinical coding is accurate for proper reimbursement and that coding compliance is complete. Monitors coding work and trends, then provides education where opportunities are identified. Reviews accuracy of identified data elements for use in creating data bases or reporting to the state health department. If applicable, applies Uniform Hospital Discharge Data Set (UHDDS) definitions to select the principal diagnosis, principal procedure, complications and co morbid condition, other diagnoses, and significant procedures which require coding. Apply policies and procedures on health documentation and coding that are consistent with official coding guidelines.

3. Assists with maintaining system wide consistency in coding practices and ethical coding compliance. If applicable, initiates and follows through on attending physician queries to ensure that the clinical documentation supports the patient’s treatment and outcomes. Identifies training needs for medical and coding staff. Provides written updates and spreadsheets as to data findings. Serves as a team member for internal coding accuracy audits.

4. Acts as a knowledge resource to ancillary clinical departments and revenue integrity analysts regarding charge related issues, processes and programming. Participates in company-wide quality teams’ initiatives to improve clinical documentation. Assists with education and training of Coding Apprentice or other staff involved in learning coding. Assists in creating a department-wide focus of performance improvement and quality management. Assists and participates with management through committees in order to properly educate physicians, nursing, coders, CDM’s, etc with proper and accurate documentation for positive outcomes.

5. Performs ongoing audits/review of inpatient and/or outpatient medical records to assure the use of proper diagnostic and procedure code assignments. Provides findings for use as a basis for development of HIMS compliance plans, education of clinical coding staff and functional assessments.

6. Maintains a current knowledge in all coding regulatory updates, and in all software used for coding and health information management for the operational group. Monitors and evaluates trends in DRG (MS-DRG), APC, ACG, DCG, HCC and other Health Risk Adjusted Factors appropriate to the assigned area, and the effect on Case Mix Index by use of specialized software.

7. As assigned, tracks and creates monthly reports for the Charge Description Master Planning committee to identify coding and Health Risk Adjusted Factors accuracies, potential revenue enhancement areas, and identifies opportunities for education of staff.

8. May code inpatient and outpatient records as needed. Works as a member of the overall HIMS team to achieve goals in days-to-bill.

9. Works independently under limited supervision. Uses an expert level of knowledge to provide billing guidance and oversight for one or more medical facilities. Internal customers include but are not limited to medical staff, employees, patients, and management at the local, regional, and corporate levels. External customers include but are not limited to, practicing physicians, vendors, and the community.

MINIMUM QUALIFICATIONS
Requires a level of education as normally demonstrated by a bachelor’s degree in Health Information Management and current continuing education.

In an acute care setting doing inpatient, requires Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCS-P) or Registered Health Information Technologist (RHIT) or Registered Health Information Administration (RHIA) in an active status with the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).

Demonstrated proficiency in hospital and/or multiple physician specialty coding as normally obtained through 3-5 years of current and progressively responsible coding experience required. Experience normally obtained with 2-3 year experience in CMS HCC Risk Adjustment payment methodology and coding and documentation requirements. Must possess a thorough knowledge of ICD/DRG coding and/or CPT coding principles, and the recommended American Health Information Management Association coding competencies. Requires an in-depth knowledge of medical terminology, anatomy and physiology, plus a thorough understanding of the content of the clinical record and an extensive knowledge of all coding conventions and reimbursement guidelines across all services lines. Excellent written and oral communication skills are required, as well as effective human relations skills for building and maintaining a working relationship with all levels of staff, physicians, and other contacts.

Must consistently demonstrate the ability to understand the Medicare Prospective Payment System, and the Clinical coding data base and indices, and must be familiar with coding and abstracting software, as well as common office software and the electronic medical records software.

PREFERRED QUALIFICATIONS

Additional related education and/or experience preferred.