Under the direction of Revenue Cycle Services, The Assistant Director of Health Information Management analyzes provider documentation, claims data, and coding on all diagnoses and procedures to ensure accuracy of diagnosis related grouping (DRG). The reviewer assures that the most accurate and descriptive ICD-10, CPT and HCPCS codes support the patient’s treatment and reflects severity of illness/risk of mortality. The second level reviewer also performs quality review of medical records, contributes to and validates the appropriateness of code and DRG assignment in order to facilitate consistency, accuracy and efficiency in claims processing, data collection and quality reporting.
General tasks and responsibilities will include:
- Performs secondary level reviews to validate the completeness, accuracy, and specificity of code assignments for inpatient records in accordance with established coding guidelines and enterprise policies and procedures for appropriate DRG assignment. Ensures that all documented diagnoses and procedures are properly coded.
- Validates the completeness, accuracy, and specificity of code assignments for emergency, outpatient and ambulatory surgery records in accordance with established coding guidelines to support HCC capture and CRGs.
- Participates in data quality reviews on inpatient records to validate the ICD-10 codes, MS-DRG, and APR-DRG, identify missed secondary diagnoses and procedures, PSIs, HACs and ensures compliance with all DRG mandates and reporting requirements. Analyze reports and identifies trends and statistical significance in quality metrics that will assist with focused as well as organizational process improvement.
- Participates in the denials and appeals process by reviewing cases denied and making the determination whether or not a case is appealable by using pre-established criteria, based facility policies and procedures. Ensures denials are responded to in a timely manner. Provides feedback to facility coders, validators and physician advisors on opportunities in collaboration with CDI.
- Assists in the development, implementation, and management of organizational strategy, initiatives, and/or budget and performance standards; communicates organizational objectives and goals.
- Identifies and reports on cases with documentation inadequacies, inconsistencies, and other issues with opportunities for improvement and collaborates with enterprise CDI reviewers to provide feedback and education to facility coders, DRG validators and CDIs.
- Generates physician queries as needed in order to obtain clarification of medical record documentation. Validates that physicians have been queried according to established procedure. Provide feedback to facilities on missed query opportunities in collaboration with CDI.
- Serves as departmental representative through participation in various facility and corporate wide committees, work groups, and/or initiatives. Assists in interdisciplinary efforts to review existing documentation and coding policies and procedures and makes necessary recommendations for improvement.
- Instructs physicians, nurses, health information management staff, and other appropriate personnel regarding documentation requirements as related to coding.
- Educate and mentors facility coding and validation staff. Provides orientation and boot camp training which includes new topics in coding (inpatient and outpatient), chart review, reimbursement and regulatory changes. Provides readiness assessments of new coding staff.
- Performs coding quality audits of records for ICD-10-CM, CPT, and PCS, as well as MS/APR DRGs assignment to ensure functions of the CDI and coding team are performed with a high degree of accuracy.
- Reviews coding edits for accuracy and provides feedback and education.
- Identify trends and patterns in coding and documentation variances, monitor quality and provide education to ensure compliance with pertinent regulations and guidelines.
- Research coding updates, new procedures, and disease pathophysiology and documentation requirements. Provide presentation/educational materials (recognized resources) to CDI and Coding staff.
- Implement coding initiatives, goals and objectives for all facilities. This position oversees all ongoing activities related to the development, implementation and maintenance of inpatient and outpatient coding policies.
- Ensures all coding and CDI staff abides by the standards of ethical coding as set forth and updated by AHIMA and ACDIS.
- Performs all related assignments.