Coding Appeals Specialist

St. Luke's University Health Network•Allentown, PA

3d•Onsite

About The Position

The Coding Appeals Specialist analyzes patient medical records, claims data and coding on all diagnosis and procedure codes to assure properly assigned MS-DRG for the purposes of appealing proposed MS-DRG and coding changes by insurance providers or their auditors. Assures that the most accurate and descriptive codes from the AHA ICD-9-CM/ICD-10-CM/PCS diagnoses and/or procedures support the services/treatment rendered.

Requirements

RHIA, RHIT and/or CCS with knowledge of ICD-9-CM and ICD-10-CM/PCS diagnosis/procedure coding and MS-DRG assignment.
Minimum of 5 years coding experience in an acute care, teaching hospital, inpatient setting required.
Minimum 5 years demonstrated inpatient and/or outpatient coding experience in acute care, teaching setting.
Knowledge of anatomy and physiology, pathophysiology, and medical terminology required.
Working knowledge of ICD-10-CM/PCS and ability to understand complex disease processes strongly preferred.
Possesses extensive knowledge of reimbursement systems; extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding and, as needed, medical necessity.

Nice To Haves

Previous experience with electronic patient medical record/EPIC and 3M encoding system preferred.

Responsibilities

Conduct retrospective medical record reviews for diagnosis and procedure code assignment and MS-DRG accuracy.
Identify and provide feedback, including identification of trends, to the Network Coding and CDMP Managers for education of the medical staff, clinical documentation professionals and the coding professionals on documentation issues that affect proper documentation and coding of documented medical care for appropriate reimbursement.
Work with the physician liaison in review of patient medical records identified by RAC/MIC/CGI/QIO and other outside auditors in retrospective reviews for DRG and coding-related issues. May participate in review of other medical necessity issues as needed.
Develop and apply appeal arguments to defend the coding of and by the coding professionals and be able to refute the coding determination made by the outside payor including but not limited to CMS, Aetna, IBC, Omniclaim, QIP, Gateway Health, etc.
Draft appeal letters, including the coding argument, to support network coding.
Identify clinical documentation improvement issues and through excellent communication with physicians, nurses, coding and other members of the health care team and work independently to resolve such issues.
Participate as needed in Administrative Law Judge (ALJ) hearings.
Spends approximately 20% of their time weekly coding/abstracting patient medical records according to ICD-10-CM/PCS, UHDDS and CMS guidelines. Utilizes the 3M Encoder to verify and assign ICD-10-CM/PCS diagnosis and procedure codes, and MS-DRG assignment.
Performs data entry of coded patient medical records into EPIC, maintaining a 95% coding accuracy rate as measured through quality reviews.
Queries physicians when code assignments are not clear and consistent, or when documentation in the record is inadequate, ambiguous, or unclear for coding assignment.