Primarily code from final procedural/ surgical operative reports signed by the provider. Review complex medical records and accurately assign codes for primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT-4 coding conventions. Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and procedural/surgical techniques through participation in continuing education programs to effectively apply ICD-10-C M and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures. Correlate information from approved supporting clinical documentation not limited to Pathology, Radiology, and/or other Physician Consultations after review by the Attending Physician, wherever appropriate.
Provide education/training to physicians and other providers on coding and clinical documentation. Consult with and educate/train physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding. Provide real-time feedback to procedural/surgical providers as it pertains to proper coding and clinical documentation of services performed. Engage in provider/ department contact and education as the primary liaison for clarification of documentation and coding for defined surgical operative cases including documentation deficiencies.
Mentor and assists in the training of other coders within the department. Participate in the development of coding policies and procedures as identified. Coordinate/mentor the work of designated coding employees to ensure quality and quantity of work performed through regular audits. Assist with research and development of presentation materials for continuing education programs for physicians in their areas of specialization.
Interact with and provides high-level analysis of trends to Management, Revenue Managers, and others about Coding related issues. Researches and identifies trends in unbilled accounts. Contacts appropriate personnel for clinical documentation inefficiencies. Coordinate quality reporting measures w/ providers, revenue managers, and management. Collaborate with appeal and edit coders to expedite the resolution of accounts. Use authorized resources and systems to aid in accurate code assignment for physician and non-physician documentation and surgical abstraction. This may include but is not limited to a review of NCCI Edits, LCD's, NCD 's, use of nThrive, and other reputable coding references
