Staffing and Resources

Review the scenario and the Clinical Coding Job Description. Develop a job posting and appropriate interview questions. Provide a written report to the HIM director that contains all the deliverables outlined.

A large healthcare organization is expanding HIM centralized coding services based on the recent acquisitions of a rural hospital, long-term acute-care hospital, skilled nursing facility, and a behavioral health facility. All the coding functions for these newly acquired facilities will be centralized within the HIM department. Based on a work volume study it is estimated the HIM department will need four additional full-time equivalent (FTE) clinical coding specialists to perform the additional coding from the acquisition of these new facilities. Laura, the HIM coding manager, is responsible for working with the HR department consultant to develop a recruiting plan for these four open positions. Laura will need to provide a written recruitment plan to the HIM director of the organization.

Assumptions

The job description for the clinical coding specialist has recently been updated by Laura and is provided following this case study in figure 7.2.
Interviews for both internal and external candidates will be performed as structured interviews.
Follow the standard HR department recruitment process: All jobs are posted internally for two weeks and qualified candidates will be referred to the coding manager for interviewing. If qualified individuals are not hired internally, the job posting will then be advertised externally using the recruitment methods identified in the recruitment plan.
A different advertisement may be necessary for the internal and external job postings.

Figure 7.2. Clinical coding specialist sample position description

Clinical Coding Specialist Sample Position Description

Initial Date: 01/01/2016

Review Date: Department: Health Information Management

Job Title: Clinical Coding Specialist
Reporting Relationship: Reports to HIM Coding Manager, Health Information Management; no direct reports

Pay Grade: Non-Exempt, Grade IV

Job Purpose: The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing.

Job Responsibilities and Tasks

Clinical Classification Coding

Assigns ICD-10-CM/PCS, HCPCS, and CPT codes accurately utilizing the 3M encoder.
Assigns Present-on-Admission (POA) indicators appropriately.
Groups all coded data to MS-DRGs, APR-DRGs, and APCS utilizing the 3M encoder.
Keeps abreast of coding guidelines and reimbursement reporting requirements.
Distinguishes appropriate coding as outlined by facility’s coding guidelines.
Abides by the Standards of Ethical Coding as set forth by AHIMA and adheres to official coding guidelines.
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes by utilizing the appropriate facility querying process.
Analyzes health record documents to ensure that the information is timely, complete, and accurate according to facility standards.
Abstracting

Performs abstracting from the EHR as appropriate.
Ensures that data adheres to data standards as outlined within the HIM policies and procedures.
Electronic Health Record

Utilizes the health record documentation contained in the EHRs as the source of truth for coding.
Utilizes dual screens for coding and reviewing EHR documentation efficiently.
Identifies issues with copy and paste in patients’ EHRs and reports them to the HIM coding manager.
Job Requirements and Specifications

Proficient in the utilization of the following classification systems: ICD-10-CM/PCS, CPT, and HCPCS.
Ability to maneuver within EHR systems.
Proficient in the use of encoders within the coding process, 3M encoder preferred