Facility-Based Medical Coding Specialist
2 weeks ago
Position Overview:
The role involves independently and effectively executing the tasks of assigning precise diagnosis and procedure codes to patient health information records across various settings, including Emergency Departments, Ambulatory Surgical Centers, and Inpatient records.
All responsibilities will be conducted in compliance with:
The International Classification of Diseases - Official Coding Guidelines as mandated by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS); American Medical Association (CPT); National Correct Coding Initiative (NCCI); Uniform Hospital Discharge Data Set (UHDDS), and other relevant coding directives.
The ability to communicate effectively with healthcare providers to clarify diagnoses and procedures is essential.Understanding the clinical content of health records and abstracting relevant data is a key requirement, along with performing additional assigned duties.
The selected candidate will undergo one week of on-site training or until departmental expectations are met.
Key Responsibilities:
Demonstrate proficiency in reviewing medical records and converting clinical information into coded data.
Identify and assign appropriate codes for diagnoses, procedures, and services rendered, while also validating any Computer Assisted Coded (CAC) assignments for dual coding.
Utilize the Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software for professional surgical services, ensuring accuracy and relevance for both professional and facility services.
Employ electronic patient data systems and clinical information systems to access patient encounter information, abstracting and entering clinical data elements as required by the organization.Identify and assign principal diagnosis and procedure codes, sequencing them appropriately for accurate Ambulatory Payment Classification (APC), Medicare Severity-Drug Related Group (MS-DRG), and All Patients Refined Diagnosis Related Groups (APR-DRG) assignments, adhering to applicable coding conventions.
Exhibit knowledge of CMS HCC Risk Adjustment coding.Regularly conduct chart analyses to pinpoint areas within medical records that may contain incomplete, inaccurate, or inconsistent documentation. Review and verify chart information to ensure accuracy and completeness of diagnostic and therapeutic procedures in accordance with CMS coding rules and guidelines. Maintain departmental standards of 95% for productivity and quality.
Fully leverage available resources such as Coding Clinic and CPT Assistant to research coding issues and apply guidelines. Identify coding concerns and communicate them to supervisors as necessary. Utilize query processes when appropriate and assist in implementing solutions to minimize coding errors.
Stay updated on coding and regulatory publications, attending workshops to remain informed about current issues, trends, and changes in laws and regulations governing medical record coding and documentation to mitigate fraud and abuse risks and optimize revenue recovery.
May assist with special projects, maintaining confidentiality and fostering effective working relationships with colleagues. Communicate clearly and understandably, exercising independent judgment. Review annual ICD-10 Official Guidelines for Coding, along with quarterly Coding Clinic and monthly CPT Assistant updates.Actively participate as a member of Facility Coding Services, engaging in coding in-services, staff meetings, and performance measure reporting.
May contribute to the development of organizational procedures and attend selected national and regional coding education sessions. Perform other assigned duties as needed.Qualifications:
Basic Qualifications:
Experience
A minimum of two years of experience in a related coding field or 18 months within an apprenticeship program.
Education
A High School Diploma or General Education Development (GED) is required.
License, Certification, Registration
The candidate must possess one of the following certifications:
Registered Health Information Technician Certificate
Registered Health Information Administrator Certificate
Certified Coding Specialist
Additional Requirements:
Prior experience with EMR patient documentation systems and intermediate computer skills are essential.
Advanced knowledge of disease processes, diagnostic and surgical procedures, and coding principles for ICD-10-CM, ICD-10-PCS, HCPCS/CPT classification systems, along with an understanding of government regulations and potential fraud and abuse scrutiny.
Fluency in English with demonstrated proficiency in both oral and written communication.
Strong time management, organizational, and analytical skills.
Ability to manage a substantial workload and work efficiently under pressure while meeting established deadlines with minimal supervision.
Capacity for independent thought and judgment.
Adherence to the Standards of Ethical Coding as established by the American Health Information Management Association (AHIMA).
Consistent performance in meeting departmental standards for productivity and quality.
The department will provide the final candidate with a coding skill assessment, which must be passed with a score of 75% or higher.
Academic knowledge and practical experience in coding and abstracting responsibilities within health information/medical record services.
Preferred Qualifications:
A minimum of two years of experience in a health information/medical record environment, including facility coding experience with Medicare reimbursement guidelines.
Proficient knowledge and skills in using computers and related software, including EMR systems and Microsoft Office Suite.
Ability to evaluate, analyze, and develop information regarding statistical trends and outcomes related to productivity and medical record audits.
Extensive knowledge of ICD-10 coding guidelines, with a demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.
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