Position Purpose
The Coding Lead position is accountable for responding to escalations from internal coding staff as well as external departments and costumers to ensure compliance and revenue related to reimbursement is coded and billed within appropriate timelines. This position is responsible for maintaining departmental standard work and keeping abreast of continual changes in coding and billing guidelines and compliance related to reimbursement within federal and State regulations. This incumbent is to have expert knowledge of accurately assigning ICD-10-CM diagnostic and procedure codes for all aspects of professional services coding or facility coding.
Nature and Scope
Incumbent will also perform highly complex and specialized coding, including review analysis. The major challenge of this position is ensuring the accountable coding for each patient type is completed within designated timelines. This position is challenged to keep workflows running smoothly for the department, including charge related items in work queues to ensure correct and timely billing. This position is accountable to bring issues and the need for revised/additional policies and procedures to management's attention.
Incumbent will serve as a resource to all coders, revenue cycle staff, providers, and clinical staff on coding questions, documentation requirements, and coding guidelines. This candidate must be able to identify and resolve problems, set goals and priorities, and represent the department in a professional manner as well as in the absence of Leadership, as assigned.
Specific job responsibilities by section include:
HIM Coding Lead
(Facility):
This list is to include but is not limited to coding and resolving escalations regarding; Acute Inpatient/Outpatient, Level II Trauma, Inpatient Rehab Facility, Home Health, Hospice and Hospital Outpatient Departments. Feedback and correction of ICD-10-CM/PCS and CPT code assignments, corrections and advice must be consistent with CMS Official Guidelines, regulatory agencies and hospital specific bylaws and guidelines.
Other responsibilities include:
• Work in collaboration with other Coding Lead staff members and colleagues to facilitate timely completion of critical medical record reviews for coding accuracy as directed or otherwise needed by CDI department, Quality and Compliance department, Business office, Data Integrity department, and other departmental business partners as needed.
• Identify Patient Safety Indicators and Hospital Acquired Conditions as being correctly coded and assist Clinical Documentation teams in making meaningful documentation clarifications.
• Reviews cases coded by staff and contract coders for accuracy and compliance with Coding Clinic and facility guidelines.
• Act as subject matter expert and advocate for coding while maintaining objective.
• Monitor quality of coding, document findings, present feedback to individual coders and report findings to Coding Leadership.
• Serve as a leader through modeling, mentoring, and training assigned staff.
• Manages assigned charge review and coding-related claim work queues to ensure timely and accurate charge capture. Accurately deciphers charge error reasons and plan follow-up steps.
• Ensures all coded services meet appropriate Medicare, National Correct Coding Initiative (NCCI) or payer-specific guidelines.
• Contacts providers and/or support staff when clarification is needed to appropriately bill for services. Ensures all coded services meet appropriate Medicare, National Correct Coding Initiative (NCCI) or payer-specific guidelines.
• Corrects claim edit errors in the work queues, assures charges provide optimal appropriate reimbursement with appropriate documentation.
• Corrects claim edit errors in the work queues, assures charges provide optimal appropriate reimbursement with appropriate documentation.
• Provides feedback and guidance to coders and clinicians on recurring errors.
• Suggests rules to proactively work these edits prior to claim edit.
• Performs other duties as assigned.
• Review and reconcile reports associated with charge review, work queues, claim edit work queues, monthly write-offs and denial management.
• Stays current on coding and compliance regulatory requirements through professional membership literature, continuing education classes, support, and networking groups.
• Maintains coding certification and attends in-service training as required.
• Identify and troubleshoot EMR coding queues and encoder workflows consistent with requirements of Coding Leadership.
• Utilize the appropriate physician clarification process to obtain additional information that provides a codable sign, symptom, or diagnosis and/or physician order.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Incumbent must have skill set to:
• Addresses appeals and complex medical record review needed for insurance denials to facilitate expedient resolution and reimbursement.
• Participates in mandated Medical Record Review processes.
• Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.
• Ensures that all factors necessary for assigning accurate DRG, ICD-10 CM, ICD-10 PCS and/or CPT, HCPCS, E & M and modifiers are present, and that related diagnoses are ranked properly when applicable.
• Assign accurate present on admission indicators when applicable.
• Provides information and responds to inquiries regarding medical documentation and DRG's, PSI's and HAC's to CDI staff including Utilization and Quality Assurance Departments when needed.
• Knowledge of discharge disposition and reimbursement outcomes.
• Adherence to Health Information Management (HIM) Coding policies.
• Adherence to The Joint Commission (TJC) and other third-party documentation guidelines in an effort to continually improve coding quality and accuracy.
• Responsibility for maintaining coding certification and referencing current ICD-10 coding guidelines and regulatory changes.
• Participates in performance improvement initiatives as assigned.
The incumbent must consistently meet or exceed productivity and quality standards as defined by the HIM Coding Leadership.
Telecommuting is allowed with approval from HIM Management.
KNOWLEDGE, SKILLS & ABILITIES
- Expert knowledge and specific details of coding conventions and use of coding nomenclature consistent with CMS' Official Guidelines for Coding and Reporting ICD-10-CM coding.
- Expert knowledge of Anatomy and Physiology of the human body, Pharmacology, Disease Pathology, and Medical Terminology in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures performed.
- Accurate translation of written diagnostic descriptions to appropriately and accurately assign ICD-10-CM diagnostic codes and procedural codes to obtain optimal reimbursement from all payer types, including Medicare/Medicaid, private and commercial insurance payers.
- Knowledge of clinical content standards.
- Ability and knowledge of the appeal process to ensure accurate reimbursement.
- Utilize critical thinking and problem-solving abilities.
- Ability to work well with others.
- Uphold a strong work ethic characterized by honesty and dependability.
- Demonstrate personal time management skills, including organization, prioritization, and multitasking.
- Adherence to company policies, procedures, and directives.
This position does not provide patient care.
Disclaimer
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications
Requirements - Required and/or Preferred
NameDescription
Education:
Must have working-level knowledge of the English language, including reading, writing and speaking English. High School Diploma and/or GED required. Associates degree preferred.
Experience:
A minimum of 5-8 years of previous facility and/or pro-fee coding experience required. Experience and knowledge in coding compliance criteria for all patient encounter types preferred.
License(s):
None
Certification(s):
CPC, CCS and/or CCS-P required. (Excludes apprenticeship classification)
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, Power Point, Excel, and Word. Must have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
