Hospital Coding Quality Specialist - Inpatient
Aurora Health Care, Allenton, WI, United States
Overview
Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition. Ensure accurate coding for outpatient, day surgery and inpatient records. Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions.
Responsibilities
Work collaboratively with coding leadership to review records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding, which may provide visibility into documentation driving codes.
Identify focused prospective records that need to be reviewed in collaboration with coding leadership.
Identify coder education opportunities, team trends, and topics to mandate for second level account review before the account is final coded.
Review encounters flagged for second level review (e.g., hospital acquired conditions [HACs], complications, core measures or trends) as identified by coding leadership. Perform review of coded encounters for appropriate risk adjustment, including accurate severity and risk of mortality assignment.
Participate in the Clinical Documentation Improvement and Hospital Coding alignment process. Review accounts with mismatched DRG assignments following notification from the inpatient coder. Determine the appropriate DRG based on coding guidelines. Provide follow-up to the clinical documentation nurse with rationale on final outcome. Recommend educational topics for coders and clinical documentation nurses based on observations from reviewing mismatches.
Participate in hospital coding denial and appeal processes as directed. Ensure timely review and response to third-party payer notifications of claims where codes are denied. Determine if an appeal will be written based on coding guidelines and provider documentation.
Follow up on overpayment or underpayment denials by rebilling accounts to ensure appropriate reimbursement. Present all trends to coding leadership in a timely manner and log for historical tracking purposes.
Investigate and resolve edits or inquiries from the billing office or patient accounts to prevent delays in claim submission due to open questions related to coding. Clarify changes in coding guidance or educational materials.
Maintain continuing education credits and credentials by staying current with knowledge trends, legislative issues, and technology in Health Information Management. Identify opportunities for continuing education for the hospital coding team.
Licensure, Registration, and/or Certification Required
Coding Specialist (CCS) certification issued by AHIMA, or
Health Information Administrator (RHIA) registration issued by AHIMA, or
Health Information Technician (RHIT) registration issued by AHIMA
Education Required
Associate's Degree in Health Information Management or related field.
Experience Required
Typically requires 5 years of experience in hospital coding for a large complex health care system, including hospital coding, denial review and/or coding quality review functions.
Knowledge, Skills & Abilities Required
Demonstrated leadership skills and abilities.
Knowledge of National Council on Compensation Insurance (NCCI) edits, and local and national coverage decisions.
Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, G-codes, HCPCS codes, CPT modifiers, APCs, and MS-DRGs.
Advanced knowledge of Microsoft Office applications (Excel, Word, PowerPoint, Teams).
Advanced knowledge of anatomy and physiology, medical terminology, pathophysiology, pharmacology, and related clinical concepts.
Expert knowledge of coding workflow and optimization of technology, including navigating electronic health records and HIM/billing systems.
Excellent communication and reading comprehension skills.
Strong analytical aptitude with high attention to detail and accuracy.
Ability to take initiative and work collaboratively with others.
Experience with remote work force operations.
Strong ethics.
Physical Requirements And Working Conditions
Exposed to a normal office environment.
Must be able to sit for extended periods of time.
Must be able to continuously concentrate.
Position may require travel to other sites and may involve road and weather hazards.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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Reviews coded health information records to evaluate the quality of staff coding and abstracting, verifying accuracy and appropriateness of assigned diagnostic and procedure codes, as well as other abstracted data, such as discharge disposition. Ensure accurate coding for outpatient, day surgery and inpatient records. Verifies all codes and sequencing for claims according to American Hospital Association (AHA) coding guidelines, CPT Assistant, AHA Coding Clinic and national and local coverage decisions.
Responsibilities
Work collaboratively with coding leadership to review records with focused diagnosis and procedure codes, including specific APCs, DRGs and OIG work plan targets to assure compliance in all areas of coding, which may provide visibility into documentation driving codes.
Identify focused prospective records that need to be reviewed in collaboration with coding leadership.
Identify coder education opportunities, team trends, and topics to mandate for second level account review before the account is final coded.
Review encounters flagged for second level review (e.g., hospital acquired conditions [HACs], complications, core measures or trends) as identified by coding leadership. Perform review of coded encounters for appropriate risk adjustment, including accurate severity and risk of mortality assignment.
Participate in the Clinical Documentation Improvement and Hospital Coding alignment process. Review accounts with mismatched DRG assignments following notification from the inpatient coder. Determine the appropriate DRG based on coding guidelines. Provide follow-up to the clinical documentation nurse with rationale on final outcome. Recommend educational topics for coders and clinical documentation nurses based on observations from reviewing mismatches.
Participate in hospital coding denial and appeal processes as directed. Ensure timely review and response to third-party payer notifications of claims where codes are denied. Determine if an appeal will be written based on coding guidelines and provider documentation.
Follow up on overpayment or underpayment denials by rebilling accounts to ensure appropriate reimbursement. Present all trends to coding leadership in a timely manner and log for historical tracking purposes.
Investigate and resolve edits or inquiries from the billing office or patient accounts to prevent delays in claim submission due to open questions related to coding. Clarify changes in coding guidance or educational materials.
Maintain continuing education credits and credentials by staying current with knowledge trends, legislative issues, and technology in Health Information Management. Identify opportunities for continuing education for the hospital coding team.
Licensure, Registration, and/or Certification Required
Coding Specialist (CCS) certification issued by AHIMA, or
Health Information Administrator (RHIA) registration issued by AHIMA, or
Health Information Technician (RHIT) registration issued by AHIMA
Education Required
Associate's Degree in Health Information Management or related field.
Experience Required
Typically requires 5 years of experience in hospital coding for a large complex health care system, including hospital coding, denial review and/or coding quality review functions.
Knowledge, Skills & Abilities Required
Demonstrated leadership skills and abilities.
Knowledge of National Council on Compensation Insurance (NCCI) edits, and local and national coverage decisions.
Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, G-codes, HCPCS codes, CPT modifiers, APCs, and MS-DRGs.
Advanced knowledge of Microsoft Office applications (Excel, Word, PowerPoint, Teams).
Advanced knowledge of anatomy and physiology, medical terminology, pathophysiology, pharmacology, and related clinical concepts.
Expert knowledge of coding workflow and optimization of technology, including navigating electronic health records and HIM/billing systems.
Excellent communication and reading comprehension skills.
Strong analytical aptitude with high attention to detail and accuracy.
Ability to take initiative and work collaboratively with others.
Experience with remote work force operations.
Strong ethics.
Physical Requirements And Working Conditions
Exposed to a normal office environment.
Must be able to sit for extended periods of time.
Must be able to continuously concentrate.
Position may require travel to other sites and may involve road and weather hazards.
This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.
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