The Corporate Coding Specialist performs coding and abstracting for all Chapters Health System subsidiaries including hospice, physician services, palliative care and PACE encounters. The Corporate Coding Specialist analyzes and interprets the documentation in the medical record and abstracts the data elements into the electronic medical record utilizing ICD-9-CM and CPT-4 coding systems.
- Candidate should be eligible or have one or more of the following credentials: RHIA or RHIT, CCS, CCS-P, CCA, CPC, CEMC. If candidate is eligible to take one of the certification exams, they must obtain their certification within twelve months of employment.
- Minimum of two years of health information management and/or physician/ancillary coding experience
- Associates degree or higher preferred
- Completion of a coding certificate program with American Health Information Management Association (AHIMA) approval status preferred
- Knowledge of database applications and spreadsheet design
- Knowledge of: ICD-9-CM, and CPT coding guidelines; medical terminology; anatomy and physiology; Medicare/Medicaid hospice and palliative care reimbursement guidelines
- Knowledge of evaluation and management coding and documentation guidelines.
- Knowledge of Clinical Documentation Improvement guidelines for documentation requirements related to code assignment
- Familiarity with electronic medical record systems preferred
- Working knowledge of 3M encoder preferred
- Excellent organizational skills with attention to detail
- Excellent communication skills and ability to provide presentations to medical staff and clinicians regarding coding and documentation requirements
- Valid driver's license and automobile insurance as per policy*
- Ability to lift and move/transport multiple charts
- Ability to bend and reach in order to access charts
- Satisfactorily complete competency requirements for this position
Responsibilities of all employees:
- Represent the Company professionally at all times through care delivered and/or services provided to all clients
- Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
- Comply with Company policies, procedures and standard practices
- Observe the Company's health, safety and security practices
- Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
- Use resources in a fiscally responsible manner
- Promote the Company through participation in community and professional organizations
- Participate proactively in improving performance at the organizational, departmental and individual levels
- Improve own professional knowledge and skill level
- Advance electronic media skills
- Support Company research and educational activities
- Share expertise with co-workers both formally and informally
- Participate in Quality Assessment Performance Improvement activities as appropriate for the position
- Analyzes and interprets information in the medical record and assigns the correct code(s) utilizing ICD-9-CM and or CPT-4 classification system to the diagnoses/procedures of medical records according to the coding guidelines.
- Abstracts all necessary information from medical records to identify the terminal diagnosis and any related complications and co-existing conditions for hospice terminal diagnosis
- Abstracts all necessary information from medical record to identify all diagnosis and encounter data required for risk adjusted coding requirements in PACE programs
- Reviews medical staff documentation and assigns appropriate procedure codes including evaluation and management services
- Performs comprehensive review for the record to assure the presence of all technical component parts such as: patient and record identification, signatures and dates where required, and other necessary data elements
- Reviews the admission documentation to ensure technical documentation requirements are met and hospice diagnosis(es) are assigned within 2 days of admission. Verifies the accuracy of data elements abstracted into the electronic medical record as needed
- Works collaboratively with the Clinical Documentation Improvement Specialists to provide feedback regarding documentation and to support education initiatives
- Serves as a coding resource to the medical staff to provide feedback regarding documentation requirements for correct coding
- Performs coding for physician encounters at the minimum productivity and quality performance levels.
- Assists Lead Corporate Coding Specialist with suggestions for coding and documentation education based on findings during record abstracting
- Communicates with medical staff as needed to clarify documentation for appropriate code assignment
- Reviews National Correct Coding Initiative (NCCI) edits in conjunction with Accounts Receivable to resolve pre-billing edits related to coding
- Evaluates medical record documentation for appropriate provider coding by ensuring that procedural codes and other documentation accurately reflect and support the visit, and to ensure that the information complies with regulatory standards and guidelines
- Makes recommendations for changes in provider and entity documentation to the manager to support ongoing improvement of clinical documentation and coding accuracy
- Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation
- Works cooperatively with Health Information Management (HIM) and Clinical Documentation Improvement Staff on related topics and initiatives
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC) adhering to the official coding guidelines
- Protects the confidentiality and privacy of patient information
- Maintains knowledge of current coding guidelines and obtains continuing education units to maintain coding credentials.
- Assists with preparing the organization for changes in coding requirements (i.e. ICD-10-CM Preparedness)
- Participates on Special Projects and Committees as assigned
- Other duties as requested by Director of Corporate HIM, Coding & privacy Officer