Ambulatory Clin Doc Integrity Spec - CFH

Overview

Performs ambulatory chart review to determine appropriate code assignment based on documentation in the chart to support clinical care provided, including preventives, Medicare Annual Wellness Visits, lowest and highest CPT E/M level, New Patient visits versus Consultation, and medical necessity. Assists in the provision of an efficient and effective clinical coding service within Carle by providing accurate and timely auditing and coding education to providers and coding team members to include CPT E/M coding, CPT Procedural Coding, and ICD10CM coding, as applicable. Ambulatory CDI work closely with HIM leadership and Compliance to assure Carle providers and coding team members are following all regulatory requirements for code assignment. Ambulatory CDI helps identify training needs through ongoing internal provider and staff audits and assists with remediation and reaudit post education. Ambulatory CDIs are responsible for producing coding education materials in formats such as Tips, power point or one to one sessions and group education sessions. Sends out notifications and queries to physicians in the EMR. Responsibilities