at Guidehouse in Springfield, Illinois, United States
Job Family :
Travel Required :
Clearance Required :
What You Will Do :
The Coding Quality Reviewer shall report directly to the Internal Quality Control Director and will be responsible for accessing and reviewing the medical record documentation, coding and abstracting accuracy as defined in quality review policies and facility guidelines utilizing ICD-10 CM/PCS and CPT coding classification systems. Review of patient records will be conducted utilizing the facility EMR, scanning technology and/or other established methods. All reviews will be entered daily into Guidehouse proprietary quality review tracking and trending software and will respond to coder rebuttals in a timely manner (timeline defined in quality review policies and procedures). This position will perform any and all related job duties as assigned.
Essential Job Functions
+ Strong computer knowledge (well versed in excel and word)
+ Excellent verbal and written communication skills
+ Meet review productivity and quality standards
+ Maintain HIPAA compliant workstations, strong knowledge of protected health information guidelines.
+ Advanced Coding Skills, ICD-10-CM/PCS and CPT
+ Strong knowledge of official coding guidelines Coding Clinics, CPT Assistant as well as associated government regulations
+ Ability to work independently and multi-task
Duties and Responsibilities
+ Quality reviewer will be responsible for reviewing the entire patient record documentation for the date of service being audited to validate all code and abstracting data elements.
+ Validation of the applicable code elements i.e. DRG, diagnosis, procedure, modifier and/or Evaluation and Management code level assignments are based on the following: supporting patient record documentation, Official Coding Guidelines (ICD-10 CM/PCS and CPT), Coding Clinics, CPT Assistant and any other federal coding guidance or regulation. All codes assigned should be supported by chart documentation and clinical evidence and/or treatment and monitoring.
+ Ensure coding quality review percentage or number of accounts per coder stipulated in client contract and on review assignment list for each coder’s work is conducted monthly for facilities the reviewer is assigned.
+ Coding quality review will be conducted to identify abstracting (to include dc disposition and POA indicators), ICD-10-CM, ICD-10-PCS, CPT, modifier, and HCPCS coding errors for codes assigned by the coding team (see quality review policies for review details).
+ Reviewer will run coder productivity reports (where applicable) to pull random sample accounts for review and to ensure review numbers or percentages are met
+ Review coding and abstracting (as defined by the facility/client) on patient types assigned to review: inpatient, ambulatory surgery, observation, emergency room with or without E/M levels, clinic, ancillary, diagnostics, etc to assure 95% coder accuracy (or as stipulated by client contract).
+ Become familiar with any facility specific coding guidelines and know where to access.
+ Required to read all Coding Clinics and CPT Assistant updates published by the education team and stay abreast of all new coding guidelines.
+ Ensure code recommendations entered into GuideAudit are supported by quoting AHA official Coding guidelines, Coding Clinics, CPT Assistant and/or other official coding references. Reviewers shall also document the specific record documentation that supports any code recommendation.
+ Notifies each coder when monthly review has been completed and respond to coder rebuttals in timely manner (see quality policy and procedures for required timeline requirements)
+ Enter review findings daily into quality software OR at a minimum within 24 hours of review (exception is pre bill accounts which MUST be entered same day received and reviewed)
+ Conduct coder pre bill reviews as priority and complete the review and corresponding data entry into GuideAudit same day received
+ Communicate (via email) coder quality pre bill score to coder, coding managers (onshore, offshore and subcontractors), Coding Director, IQC Director and/or Pro Fee Supervisor and VP Quality
+ Communicate in a professional, educational, non-threatening mentorship manner with the coding team in coding quality recommendations and rebuttal discussions.
+ Follow review escalation policy when coder/reviewer disagreements occur (see quality review policy/procedures).
+ Notify Director, Supervisor and VP of Quality when coders fall below accuracy standard, coding risk areas and error trends are identified for a specific facility and/or coder.
+ Assist Coders in answering coding/abstracting questions resulting from quality reviews.
+ Conduct coder intensification reviews for Coders who fall below the stipulated accuracy rate as part of the corrective action plan (per guidance of Review Supervisor or IQC Director)
+ Maintain working knowledge of ICD-10-CM/PCS and CPT coding principles, government regulations, official coding guidelines, and third-party requirements regarding documentation and billing.
+ Ability to maintain review productivity standards as follows for type of reviews performed:
+ Inpatients – 1.5 – 2 charts/hour.
+ Outpatient surgery – 3 charts/hour
+ Observation – 3 charts/hour
+ Emergency room/clinics – 11 charts/hour
+ Emergency room with Evaluation & Management leveling – 7-8 charts per/hour
+ Ancillary/diagnostic – 15 charts/hr.
- This excludes outliers (i.e. long length of stay, voluminous or very complex records etc) which will be captured on activity review summary
+ Complete review activity summary daily (productivity summary) for each facility noting any activity that prevents reviewer from meeting productivity standards and submit to IQC Director and Professional Fee Supervisor on a weekly basis (utilized in calculation of quality review FTEs and productivity).
+ Assist as needed in the review of external coding audit company findings and assist in in formulating a response as requested
+ Participate in client conference calls and mandatory monthly quality team stand-up calls. Responsible to review the minutes of monthly quality stand up calls if not able to dial into the conference call (minutes are posted on the portal).
+ Provide company support for the creation, maintenance and ongoing operation of an efficient and accurate Quality Improvement Plan that is compliant with Local, State, and Federal Government Regulations.
+ Work with the Coding Solutions Division to provide on-going coding education resulting from the Quality Reviews when requested
+ Maintain open lines of communication serving as a liaison between client, Coders, and Coding Solutions Division to ensure that all parties are kept up to date on specific hospital guidelines/policies.
+ Participate in company Coding Solutions Division Meetings as requested.
+ Reviewer must be able to work independently while maintaining productivity standards.
+ Advanced computer skills are required to handle connection issues, downloads and to review specific programs.
+ Reviewer downtime due to connectivity issues (client system, GuideAudit or other) must be reported immediately to the IQC Director and/or Pro Fee Supervisor to ensure appropriate actions taken to resolve to ensure minimal downtime and interruption to work flow/productivity.
+ Facility access/connectivity problems should be reported to onshore Guidehouse Coding Manager for the facility, IQC Director and/or Pro Fee Supervisor to provide direction about next steps to resolve the issue as soon as possible.
+ Reviewers are responsible for checking and responding to Guidehouse emails at a minimum; at the beginning of their shift, at least every two hours during working hours AND at the end of their shift. The