Status: Full Time

Shift: Days; Monday - Friday 40 hrs/week

Exempt: No

Other information:

Education:
High school diploma/equivalent is required.
Associate’s degree or higher is preferred.  
Successful completion of Basic Coding Course, Medical Terminology Course, and Basic Human Anatomy.  

Licensure/Certification/Registration:
RHIA, RHIT, CCS, CPC, or CPC-A is required. CPC-A will be evaluated based on an internal testing method (AHIMA-Based Coding Test). A passing grade of 80% must be achieved.  

Experience/Skills:
Minimum of two years’ experience required in coding evaluation and management services and procedures preferred. 
or 
One year experience in chart auditing with Provider/Clinic Staff education preferred.
or
Minimum of one year of outpatient coding experience assigning ICD-10-CM and CPT codes to outpatient records including but not limited to diagnostic, procedural and E/M codes preferred.

Working knowledge of computers and keyboards.
Must be polite and able to promote positive public relations with medical staff, co-workers and any other persons within the health system.

Physical Demands:
Strength: Sedentary
Push: Occasionally
Pull: Occasionally
Carry: Occasionally
Lift: Occasionally
Sit: Frequently
Stand: Occasionally
Walk: Occasionally

Summary:

Ensures all Outpatient, Anesthesia, Interventional/Diagnostic Radiology and North Oaks Clinic Records, (i.e. Emergency Department, Series, Observation and any other Outpatient records) are coded accurately using ICD-10-CM and CPT diagnostic, procedural and evaluation and management codes in accordance with applicable regulatory guidelines, compliance policies and standards of ethical coding.Reviews records for completion of documentation ensuring documentation reflects the severity of illness, the services provided and the level of service billed.Reviews Clinic, Outpatient Hospital, Observation and Inpatient records to ensure documentation reflects the severity of illness of the patient, the services provided and the level of service billed. Responsible for Coding/Auditing the Professional component of E&M, Surgical Coding for Outpatient, Observation, Inpatient and Chargemaster.

Responsibilities:

1. Accurately codes, abstracts records by reviewing all documentation including dictated reports and/or ancillary results as needed to assign the definitive diagnostic, procedural and evaluation and management codes as substantiated by physician documentation.
2. Assigns diagnosis and procedure codes as specified in the Official Guidelines for Coding and Reporting, based on substantiated documentation in the record.
3. If diagnoses cannot be substantiated due to lack of physician documentation, a physician query will be issued for clarification of diagnosis.
4. Complete required abstracting
5. Assists with account and claim work queues.
6. Must maintain coding accuracy/quality in accordance with internal quality monitoring and quality standard of 97%
7. Maintains coding productivity standards as outlined below:ED Diagnostic & E&M - 66/dayED E& M Only - 80/dayOP, ED, Series Records -19/hourL&D, Observation - 19/hour
8. Accurately Code/Audit Inpatient and Outpatient Hospital services for NOPG Clinic Provider reviewing all documentation including dictated reports and/or ancillary results as needed to assign the definitive procedural and evaluation and management codes as substantiated by physician documentation.
9. Meet with physicians to ensure physician documentation substantiates the severity of illness of the patient, the services provided and the level of care billed.
10. Maintain physician reports indicating documentation deficiencies by physician in an effort to determine education deficits.
11. Verify all demographic information that impacts billing and report all errors to PBS- (Professional Billing Services) staff.
12. Review charges and documentation in the patient medical record, identify errors, deficiencies, and/or variances with correct coding standards. Responsibilities to include but not limited to posting charges and working assigned WQ’s.
13. Initiate the addition of CPT/HCPCS codes to be added to clinic charge master when applicable.
14. Work directly with clinics to improve charge capture and documentation.
15. Preparation of materials for New Provider Orientation.
16. Responsible for assisting Billing and Collection staff with identifying appropriate documentation needed for appeals/denials.
17. Assist with Annual Provider chart audits in a timely manner.
18. Accurately enters E&M level charges on all patients admitted through the ED as indicated.
19. Maintains coding competency and enhance coding expertise through ongoing educational programs applicable to coding and compliance by obtaining required CEU’s to maintain coding credentials.
20. Maintains good working relationship with all personnel.
21. Adhere to hospital and department policies and procedures and all other applicable regulatory guidelines such as JCAHO, CMS, AMA CPT assistant, AHA Coding Clinic and NOHS compliance programs for confidentiality, safeguarding of protected health information.
22. Attends hospital and department in-service education programs as scheduled
23. Adhere to other job related instructions and other job related duties as requested.
24. Adhere to standards of ethical coding and correct coding initiative guidelines.
25. Keep personal items and office equipment in order to prevent injury to self and others.
26. Must be highly motivated, a self-starter and work independently.
27. Meet with physicians to ensure physician documentation substantiates the severity of illness of the patient, the services provided and the level of care billed.
28. Maintain physician reports indicating documentation deficiencies by physician in an effort to determine education deficits.
29. Verify all demographic information that impacts billing and report all errors to PBS- (Professional Billing Services) staff.
30. Review charges and documentation in the patient medical record, identify errors, deficiencies, and/or variances with correct coding standards. Responsibilities to include but not limited to posting charges and working assigned WQ’s.
31. Initiate the addition of CPT/HCPCS codes to be added to clinic charge master when applicable.
32. Work directly with clinics to improve charge capture and documentation.
33. Preparation of materials for New Provider Orientation.
34. Responsible for assisting Billing and Collection staff with identifying appropriate documentation needed for appeals/denials.
35. Assist with Annual Provider chart audits in a timely manner.
36. Maintain working relationship with coding vendor which includes but not limited to reviewing charge data, keying charge data, acting as a liaison between Providers and coding vendor, and assisting with denials.
37. Review billing audits for NOPG Clinic Providers and performs follow-up education and re-audits as appropriate with providers and staff.
38. Continuously evaluate the quality of clinical documentation to spot incomplete or inconsistent documentation for NOPG Clinic Provider encounters that impact charge and/or code selection. Communicates variances to appropriate manager.
39. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and the American Academy of Professional Coders.
40. Assist in communicating updates for LCD’s/NCD’s to applicable clinic staff.
41. Keeps abreast of new technology in documentation, charging, chargemaster coding and abstracting software and other forms of automations and stays informed about transaction code sets, HIPAA requirements, and other future issues impacting the billing and coding function.
42. Perform special project or random audits.
43. Perform Chargemaster reviews, including but not limited to, review all ICD-10-CM diagnoses, CPT procedures, and HCPCS codes for additions, deletions, or revisions.
44. Performs charge master compliance audits.
45. Conduct analysis and prepare reports as directed.
46. Assist in preparation of action plans for compliance and/or Administration.
47. Maintain coding competency and enhance coding expertise through ongoing educational programs applicable to coding and compliance.
48. Maintain coding credentials and timely complete CEU’s as required.
49. Remain knowledgeable of all AHA Coding Clinics for ICD-10-CM, CPT& HCPCS updates, and any other applicable coding guidelines in accordance with all regulatory requirements.
50. Use interpersonal skills effectively to build and maintain cooperative working relationships.
51. Inspire confidence from physicians and co-workers by performing and communicating in a highly professional, responsive and supportive manner at all times.
52. Demonstrate consistent willingness to maintain good working rapport with all personnel.
53. Communicate effectively, expressing ideas clearly, actively listening and always follow appropriate channels of communication.
54. Demonstrate responsiveness to others ensuring complete follow-up on matters requiring additional attention.
55. Remain knowledgeable of and adheres to hospital and department policies and procedures.
56. Perform other duties as required and/or directed.
57. Follow standards of ethical coding and adheres to correct coding initiative guidelines.58. Follow North Oaks Health System's compliance programs and all federal and state regulatory guidelines.