QA - HIM Services

Roles and Responsibilities:

Auditing and reviewing medical documentation for appropriate ICD and CPT coding
and ensuring that codes tally with doctors’ diagnosis.
Asking explanation from physicians when code assignments are not straightforward or
documentation in the record is inadequate, ambiguous, or unclear for coding purposes
Ensuring compliance with medical coding policies and guidelines.
Be updated about new coding rules as codes change from time to time.
Collecting and distributing coding related information and billing issues.
Exceptional Knowledge of medical terminology, anatomy, physiology, disease
processes, and pharmacology.
Work as part of a team and achieve the team quality and productivity standards.

Required Expertise & Qualification:

Life Science graduation or any equivalent graduation with Anatomy/Physiology as
main subjects
3 to 5 years of work experience as a medical coder.
Any one of the following coding certifications CPC, COC, CRC, CPCP from AAPC CCS,
CCSP, CCA from AHIMA
Proficient computer skills.
Excellent communication skills, both verbal and written.
Strong people skills & Outstanding organizational skills.
Ability to maintain the confidentiality of information.

An Evaluation and Management (E/M) IP & OP Auditor is a senior-level medical coding professional responsible for ensuring that physician documentation and code selection for Inpatient (IP) and Outpatient (OP) encounters are accurate, compliant, and supported by clinical evidence.

Following the major E/M guideline overhauls in 2021 (Outpatient) and 2023 (Inpatient/Observation), this role focuses heavily on auditing Medical Decision Making (MDM) and Total Time to protect the organization from compliance risks and revenue loss.

1. Job Summary

The E/M Auditor reviews medical records across various settings—including hospitals, clinics, and emergency departments—to validate the level of service billed.[1] They serve as a bridge between the coding team and healthcare providers, identifying documentation gaps and providing data-driven education to improve coding accuracy.

2. Core Responsibilities

Audit Performance (Inpatient & Outpatient)

• IP Focus: Audit hospital admissions, daily progress notes, and discharge services (99221–99239). Validate that the complexity of the patient's condition justifies the level of care in an acute setting.
• OP Focus: Audit office visits (99202–99215) and Emergency Department (ED) visits (99281–99285), ensuring code selection aligns with the 2021/2023 MDM or Time-based rules.
• Pre-billing & Post-billing Audits: Conduct "shadow audits" before claims are submitted (pre-bill) to prevent denials, and retrospective audits (post-bill) to assess long-term compliance.
• MDM & Time Validation: Scrutinize the "Amount and Complexity of Data Reviewed," "Number and Complexity of Problems Addressed," and "Risk" to ensure the MDM table is applied correctly.

Provider Education & Feedback

• Documentation Improvement: Identify "cloning" (copy-pasting), lack of specificity in the plan of care, or insufficient time documentation.
• One-on-One Education: Meet with physicians and Mid-Level Providers (PAs/NPs) to explain audit findings and provide corrective guidance.
• Reporting: Create detailed audit spreadsheets and executive summaries showing accuracy rates, financial impact, and trend analysis.

Compliance & Regulation

• Guideline Mastery: Stay current with CMS, AMA, and OIG updates.
• Edit Review: Check for National Correct Coding Initiative (NCCI) edits and ensure appropriate use of modifiers (e.g., Modifier 25 or 57).

3. Required Qualifications & Skills

Technical Skills

• Code Sets: Mastery of ICD-10-CM, CPT, and HCPCS Level II.
• Guidelines: Expert knowledge of the 1995/1997 E/M guidelines (where still applicable) and the 2021/2023/2024 E/M updates.
• Software: Proficiency in Electronic Health Records (EHR) like Epic, Cerner, or Meditech, and auditing software (e.g., 3M, RevPoint).

Education & Experience

• Education: Any graduation from medical coding.
• Experience: Usually 3–5+ years of active E/M coding experience, with at least 1–2 years specifically in an auditing or quality review capacity.

Mandatory Certifications

• CPC (Certified Professional Coder) or CCS-P (Certified Coding Specialist – Physician-based).
• CPMA (Certified Professional Medical Auditor) – Highly preferred or required within 6 months of hire.
• Optional:CIC (Certified Inpatient Coder) or CCS for facility-side auditing.

4. Key Performance Indicators (KPIs)

• Accuracy Rate: Maintaining a minimum 95% accuracy rate for audited charts.
• Audit Volume: Meeting weekly/monthly quotas (e.g., auditing 30-50 charts per week).
• Denial Reduction: Measurable decrease in E/M-related claim denials after provider education sessions.

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.