QA - HIM Services

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. They serve as a bridge between the coding team and healthcare providers, identifying documentation gaps and providing data-driven education to improve coding accuracy.

Core Responsibilities

Audit Performance (Inpatient Outpatient)

• IP Focus: Audit hospital admissions, daily progress notes, and discharge services. Validate that the complexity of the patient's condition justifies the level of care in an acute setting.
• OP Focus: Audit office visits and Emergency Department (ED) visits, 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).

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.

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

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