The Coder 1 – Inpatient, Certified, under the supervision of the Coding Supervisor, is responsible for abstracting clinical information and assigning CPT, ICD and HCPCS codes from medical records and documents to support physician professional fees, including but not limited to, outpatient and inpatient evaluation and management (E/M) services (e.g., outpatient visits, consultations, preventive care, initial admits, discharges, etc. ) along with office and invasive procedures, global surgical services, anesthesia and surgery center services in accordance with American Medical Association (AMA) and Health Care Finance Association (HCFA) documentation guidelines, American Hospital Association Official Coding guidelines (ICD), AMA's CPT definitions and instructions, along with third party payor guidelines, including Medicare and Medicaid specific policies. With the guidance from a Coder 2 - Inpatient - Certified they are also responsible to monitor and follow-up on pending documentation; to assist in the updates of the encounter forms to incorporate new and revised codes: to identify areas of educational needs; to serve as a liaison and educator between medical staff, coworkers and other staff; to research and resolve coding issues and answer questions as they relate to coding and billing, as well as entering professional hospital charges directly into Epic Resolute.
1) Interpret, abstract and complete:
a) Inpatient and surgery center medical records for evaluation and management codes, global surgical procedures, invasive bedside procedures, anesthesia and any other physician professional services from documentation to include: assignment of CPT, ICD codes and modifiers; calculate modifier and anesthesia fees; ensure that Medicare, Medicaid and third party carrier policies/regulations are followed; verify and complete log sheets; entry of codes into Epic Resolute (Resolute); and maintain a three to five day turnaround from time of discharge to time of abstraction or entry into Resolute (HPF).
b) Medical center patient records for evaluation and management codes, office procedures, ancillary services and nursing home services from documentation to include: assignment of CPT, ICD and HCPCS codes and modifiers; and ensure that Medicare, Medicaid and third party carrier policies/regulation are followed.
c) Notification of incomplete or missing documentation of patient services. Forward information to Coding Support Staff.
d) Research of missing inpatient, surgery and anesthesia charges for three main hospital sites and four main surgery center sites. Research will involve chart review and interaction with the physician to identify missing information.
e) Research of missing charges for any clinic site and outreach site. Research will involve chart review and interaction with the physician to identify missing information.
a) Audit requests specific to coding and billing issues by abstracting the patient chart information and following appropriate AMA, Medicare, Medical Assistance and contract guidelines. Compile and summarize the results by working with Inpatient Coder 2 mentor to assist. Forward the results to the Coding Supervisor.
b) Insurance edits, charge review work queue sessions and In basket issues, using coding knowledge to review and correct issues such as bundling edits, multiple procedure rules, incompatible diagnosis codes, etc. to determine appropriateness of edit, charge session or In basket and the action to be taken. Such action may include changing codes, resubmitting the claim, or writing an appeal letter to the insurance company to rebut the edit.
c) Coding trends of incorrect code applications and new industry interpretations to identify areas of education opportunity for providers and staff. Determine the appropriateness of the coding; work with the Inpatient Coder 2 mentor to contact the physician when necessary for clarification or educational purposes; responding to the patient if necessary via written communication with outcome, working with the DMG insurance department or external insurance company to resolve the issue.
d) Medical records for individual and department audits or reviews. The audits and reviews may be done for the Office of Medical Affairs, as part of a focused audit, at the request of the provider, administrator or manager, and as part of the shadowing program offered by the Coding Department. Work with Inpatient Coder 2 mentor to clarify reviews and audits.
e) Medical records to determine the appropriateness of coding, concurrent care issues and potential patterns of abuse. Includes working with appropriate DMG or external parties to resolve the issue(s).
f) Denial reports through abstraction and research to determine and resolve appropriateness of the denials. Suggest new guidelines, work queue rules and education as part of the resolution.
g) Physician compensation reports for proper coding when requested will be reviewed with Inpatient Coder 2 mentor.
a) Physicians on industry changes as they occur throughout the year. Research coding issues for and with the physicians to identify and recommend the most appropriate method of coding. Research may involve interaction with such organizations as AMA, specialty societies, or other coding sources. These educational opportunities will be evaluated with an Inpatient Coder 2 mentor.
b) By communicating the research findings and answers to the providers on an individual basis, through department meetings, written venues and other methods as needed through an Inpatient Coder 2 mentor.
c) And serve as a liaison for the providers to maintain consistency in billing practices and optimize reimbursement. Seek clarification when necessary from the Coding Supervisor.
d) Physicians and other providers on findings of personal and department audits or reviews performed by the coders and with Compliance.
e) All new providers on the coding and documentation elements necessary to accurately reflect the services provided within six weeks of their start date. The Inpatient Coder 2 mentor will assist to provide this education.
f) Existing providers on the coding and documentation elements necessary to accurately reflect the services provided within two months of the request. The Inpatient Coder 2 mentor will assist to provide this education.
4) Remain current:
a) By attending conferences, audio conferences and workshops such as the AAPC audio conferences and local chapter meetings as needed to stay current with coding and documentation guideline changes.
b) With CPT, ICD and HCPCS coding changes as well as unique documentation or coding requirements by payor types (i.e. Medicare and Medicaid) and contractual arrangements.
c) With use of Coding Library materials, DMG Coding and/or Compliance Guidelines and on line sources related to coding requirements.
d) With the current practices and procedures of the business office departments (i.e., Patient Accounts, Insurance, Workers Compensation, Patient Advocacy, etc.) to be able to understand the impact on the patient's charges, to better identify the action to be taken by these departments, and to be able to communicate to the appropriate parties, insuring the correct outcome.
e) By maintaining credentialing certification.
a) Providers through daily interactions to problem solve and trouble shoot coding issues with the authority to advise and recommend coding solutions and change codes according to documentation and coding guidelines with the assistance of the Inpatient Coder 2 mentor.
b) Coworkers to problem solve and trouble shoot coding issues through daily interactions and responses to questions.
c) Establish and maintain working relationships with providers and peers as required to perform the responsibilities of this position. Examples of such actions may be meeting with physicians and workgroup members to assist with valuing new procedures as well as obtaining clarification on potential bundling issues and denials.
d) Business office areas such as Credit, Patient Accounts and Insurance, in addition to the physician and patient care staff by acting as a coding resource to answer questions and educate on coding matters. Respond to requests in a timely, efficient and friendly manner.
e) Patients and coworkers through timely response to In baskets, coding information line questions and fee quote process.
f) And assist other departments with review of physician services and documentation, coding education and other needed assistance with help from an Inpatient Coder 2 mentor.
g) Timely and accurate coding of all provider services by keeping encounter forms current as new codes become available for every department and provider type.
h) Efficiency of DMG by identifying areas of waste or duplication and providing suggested resolution to the matter.
6) Perform other duties as assigned.
1. High school diploma or equivalent with certification as a CPC, CPC-A, RHIA, RHIT, CCS, CCS-P, CCA or CPMA.
2. Two years Outpatient Professional Coding or 1 year of inpatient coding abstraction experience.
3. Detailed knowledge of medical terminology, anatomy and physiology and disease process.
4. Detailed knowledge of CPT and ICD coding and how to interpret the contents of a medical record.
5. Knowledge of reimbursement practices for physician services.
6. Ability to work independently, establish work priorities and adjust them as the circumstances dictate in a busy area with constant interruptions.
7. Maintain patient and Medical Center confidentiality.
8. PC experience; good oral, written and problem solving skills.
9. Energetic and flexible in working as part of the team.
1. One year experience in a multispecialty setting preferred.
2. Experience with an electronic medical record.
3. Experience with Microsoft office products.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Ability to sit for extended periods while on the phone or computer.
2. Ability to continuously see fine print and to use the computer for extended periods.
3. Ability to continuously perform fine motor tasks, such as computer, calculator, writing or phone tasks.
4. Ability to hear and converse on the phone and in person.
5. Ability to safely lift and to push/pull boxes or equipment weighing up to 20 pounds.
About SSM Health Dean Medical Group–
Based in Madison, Wis., Dean Clinic consists of a network of more than 60 clinics in south-central Wisconsin. Our more than 500 physicians provide primary, specialty and tertiary care in the clinics as well as eye care through our Davis Duehr Dean locations. Dean Clinic also offers urgent care services and operates outpatient surgery centers. Dean Clinic joined SSM Health in 2013.