UPMC

Compensation

Full Description

Purpose: Review clinical documentation within the medical record to ensure that all patient resource utilization, diagnostic complications and co-morbidities have been coded in compliance with coding guidelines, third party payer and OIG regulations. Responsibilities: • Review and evaluate focused UPMC DRG medical records for accurate DRG assignment to ensure that all documented principal and secondary diagnoses, including all complications and co-morbidities, and procedures are accurately coded and sequenced according to coding and compliance guidelines. • Meet with coding management as scheduled to review progress, discuss problems, and initiate new programs or activities relative to the information obtained from these reports. Function as a resource person to respond to special audits and projects assigned by Management or requested by other departments. Perform audits as requested by internal departments and outside payers/agencies • Investigate, correct (if necessary), and respond to requests for record review relative to discharge disposition, admit or discharge date, invalid codes, etc. from requesting departments to ensure timely, accurate reimbursement. Investigate and address research accounts requiring V70.7 code assignment. Review focused charts at a rate in accordance with departmental standards. • Facilitate compliance to the Medicare 72-Hour Rule by identifying and investigating related admissions, making the appropriate adjustments to the coding system, contacting the Admitting department for registration issues, and reporting outcomes to the Patient Business Services department for appropriate reimbursement. • Coordinate DRG reimbursement issues among coding, nursing administration, Patient Business Services, medical staff, case management, and other ancillary departments directly affected by DRG assignment. • Track and report quality statistics of the coding personnel from focus chart audits and report this information to the Coding Manager on a monthly basis. • Provide coding staff with updates on any coding issues and educational information as necessary. • Counsel/train coders on problems when necessary in coordination with the Coding Manager and/or Coding Specialist and assist in correcting deficiencies in DRG assignment. • Prepare monthly productivity reports of DRG revenue profiles to identify total amount of optimization and missed opportunities. • Attend and participate in Committee meetings as requested. Investigate and respond to payment and/or DRG Assignment denials by Workers Compensation, and other insurers. • Identify and report issues and trends to the coding management. • Focus emphasis of educational presentations on accurate and thorough documentation necessary to support the coding of diagnoses that were treated, monitored and evaluated and procedures that were performed during an episode of care. • Review billing data when conducting focused chart audits to ensure it is complete and accurate. • Prepare and present in-service training on accurate DRG assignment for coding personnel, the medical staff, physician extenders (PAs, CRNPs), nursing case management and ancillary departments. • Assist the Coding Manager with auditing coders' work as requested. • Formulate physician queries that present indications, utilizing clinical judgment, of a diagnosis that is not clearly documented in the medical record and request appropriate documentation to support the additional diagnosis.