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Description:

POSITION PURPOSE

Provides high level technical competency and subject matter expertise analyzing physician/provider documentation contained in Complex Outpatient (CO)/Ambulatory Surgery health records to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Assigns appropriate Ambulatory Procedure Classification (APC) codes, required modifiers, NCCI and LCD/NCD edits.   

Utilizes encoder software applications, which includes all applicable online tools and references, in the assignment of International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis and procedure codes and Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) procedure codes. Uses encoder software and coding abstracting system edit features to resolve edits prior to completing coding.  Interprets, researches and resolves claim edits that occur after coding to support timely final claims submission.  

Assigns appropriate code(s) by utilizing coding guidelines established by:

• The Centers for Medicare/Medicaid Services (CMS) ICD-CM Official Coding Guidelines for Coding and Reporting, ICD-PCS Official Guidelines for Coding and Reporting
• American Hospital Association (AHA) Coding Clinic for International Classification of Diseases, Clinical Modification
• The American Medical Association (AMA) for CPT codes and CPT Assistant
• American Health Information Management Association (AHIMA) Standards of Ethical  
• Coding
• Revenue Excellence/Health Ministry (HM) coding procedures and guidelines  

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.  

Navigates the patient health record and other computer systems/sources to accurately determine diagnosis and procedures codes, APCs, CPT, HCPCS codes, modifiers, internal edits and claim edits that could impact hospital reimbursement.

Interprets bundling and unbundling guidelines (NCCI edits) as well as LCDs/NCDs edits and payer policies.

Works Outpatient internal and external claim edits and routes non-coding ones to appropriate owners e.g., Revenue Integrity, Billing, etc.

Adheres to Inpatient coding quality and productivity standards established by Revenue Excellence/HM.

Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous documentation.  

Utilizes EMR communication tools to track missing documentation or Outpatient  queries that require follow-up to facilitate coding in a timely fashion.

Works with HIM and Patient Business Services (PBS) teams, when needed, to help resolve billing,  claims, denial and appeals issues affecting reimbursement.

Maintains CEUs as appropriate for coding credentials as required by credentialing associations.

Maintains current knowledge of changes in Outpatient coding and reimbursement guidelines and regulations e.g., new modifiers, wound care.

Identifies, and attempts to  resolve, coding and/or EMR workflow issues that can impact coding.

Exhibits awareness of health record documentation or other coding ethics concerns. Notifies appropriate leadership for assistance, resolution when appropriate.

Performs other duties as assigned by Leadership.

Maintains a working knowledge of applicable coding and reimbursement Federal, State and local laws and regulations, the Compliance Accountability Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest ethical and professional behavior.

MINIMUM QUALIFICATIONS

Completion of an AHIMA or AAPC approved coding program or Associate’s degree in Health Information Management or a related field or an equivalent combination of years of education and experience is required. Bachelor’s degree in Health Information Management (HIM) or related healthcare field is preferred. 

Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)  or Certified Coding Specialist (CCS) is required.

Three (3) years of current acute care or Complex Outpatient experience is required. 

Extensive, comprehensive working knowledge of medical terminology, Anatomy and Physiology, diagnostic and procedural coding and APC assignment. Must