Coding And Documentation Specialist

Description

Responsible for performing routine coding reviews of Evaluation & Management documentation, identify improvement opportunities, monitor accuracy and ensure documentation compliance. Works closely with departments to ensure documentation best practice, provide coding expertise and recommendations for risk mitigation strategies as needed.

JOB FUNCTIONS:

• Review select medical records to ensure compliance with 2023 Evaluation & Management documentation and coding guidelines
• Provide limited documentation analysis for all New Providers
• Provide standardized summary of findings and recommendations to Coding Educator
• Applies CPT-4, ICD-10-CM, HCPCS and modifiers following coding standard guidelines.
• Understands current regulatory coding requirements, which include Federal, State and local guidelines.
• Keeps abreast of research projects within the department.

Requirements

Education:

• High School Diploma or equivalent.

Experience:

• Three to five years of ICD-10-CM, CPT-4, HCPCS abstracting chart notes
• Three to five years working in professional multi-specialty coding
• Teaching Physician Rule proficiency preferred
• Split/Shared Rule proficiency preferred

Certification:

• CPC certification equivalent; CPMA specialty certification required within one year of employment

PERFORMANCE REQUIREMENTS:

Knowledge, Skills and Abilities:

• Strong understanding of current regulatory coding requirements, reimbursement and billing process of services rendered in a teaching facility, medical office, hospital or Skilled Nursing Facility.
• Knowledge of medical specialties; medical diagnostic and therapeutic procedures; ancillary service
• Knowledge of clinical compliance, best practices, medical record review, legal aspects of documentation
• Knowledge and understanding of State and Federal regulations, healthcare billing practices and compliant claims preparation for Government and Commercial Payers
• Ability to understand and interpret written material, including technical material, rules, regulations, instructions, reports, charts, graphs or tables
• Proficient in various Microsoft applications such as Word, Excel and Outlook
• Excellent written and verbal communication skills.
• Excellent attention to detail.
• Ability to identify problems and find creative and effective solutions.
• Ability to research and follow up on issues.
• Proficiency testing for baseline assessment.

Equipment Operated:

• Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.

Work Environment:

• Position in a well lighted office environment. Frequent contact with a variety of people.

Physical Requirements:

• Involves sitting approximately 80 percent of the day, walking or standing the remainder. Some bending, stooping, and lifting up to 25 pounds.

Safety:

• All employees are responsible for complying with safe and healthful work practices as outlined in CCFMG's Employee Safety and Injury and Illness Prevention Program and policies and procedures specific to their department needs.