Patient Accounts Nurse Auditor - RN

Job Title: Patient Accounts Nurse Auditor - RN

Department: Patient Business Services

Job Number: 34571

Location: Memphis, TN

St. Jude Children’s Research Hospital is a world-renowned institution that is recognized as one of the best places to work in the nation. As a premier center for research and treatment of childhood catastrophic diseases, we employ a diverse team of scientific and healthcare professionals dedicated to the promise of hope. Children from all 50 states and from around the world have come through the doors of St. Jude for treatment, and thousands more have benefited from our research.

The Patient Accounts Nurse Auditor, under the supervision of the Patient Accounts Manager, concurrently reviews medical records to determine appropriate documentation and substantiates the medical necessity and coding of insurance claims. (KF)

WORK SCHEDULE:

Monday – Friday; 8:00 AM - 4:30 PM  

Job Qualifications:

EDUCATION REQUIREMENTS: 
Graduation from a school of nursing required.
 
EXPERIENCE REQUIREMENTS:
Two (2) years in a hospital business office setting performing healthcare claim audit functions and responsibilities required.
Experience using and familiarity with medical and billing claim forms preferred.
 
LICENSURE REQUIREMENTS:
Must possess a current Tennessee State Board of Nursing license if primary residence is Tennessee or a Nurse Licensure non-Compact state.
Must possess a current State Board of Nursing license in the state of primary residence if the state is a Nurse Licensure Compact state.
 
OTHER CREDENTIAL REQUIREMENTS:
Certification with the American Association of Clinical Coders and Auditors preferred.

To apply online, visit: https://jobs.stjude.org/css_external/CSSPage_Referred.ASP?Req=34571&s_cid=3-1-1853-36-25632

St. Jude Children’s Research Hospital is an Equal Opportunity Employer. St. Jude does not discriminate on the basis of race, national origin, sex, genetic information, age, religion, disability, sexual orientation, gender identity, transgender status, veteran’s status or disabled veteran’s status with respect to employment opportunities.  All qualified applicants will be considered for employment.  St. Jude engages in affirmative action to increase employment opportunities for minorities, women, veterans and individuals with disabilities.

ICD10-PCS codes for Inpatient | CPT codes for Outpatient !!!!!

Why hospitals would want procedures coded in CPT and ICD-10-PCS coding

by CARL NATALEAUG 3, 2015 - 09:15 PM

With less than two months to go, it shouldn't need repeating that ICD-10-PCS will only be used by hospitals for inpatient procedures. That means hospitals will use CPT codes for outpatient procedures. Remember that's for billing.

But in the ulcer example from ICD-10 Trainer below, they used ICD-10-PCS codes for an outpatient procedure. Yes, CPT was used for reimbursement. But this example imagined a hospital that wanted to have the same data to compare inpatient data and outpatient data.

It also allows hospitals more scheduling flexibility if medical coders are skilled in CPT and ICD-10-PCS coding.

• Let that ulcer bleed: How to code the treatment of a bleeding peptic ulcer. (ICD-10 Trainer)

• ICD-10-CM/PCS – Part 56: Amputating the little finger. (Codebusters)

Welcome to ICD10Data.com

ICD10Data.com is a free reference website that contains all of the official American ICD-10-CM (diagnosis) and ICD-10-PCS (procedure) medical billing codes. Use this site to search for any code, and to discover how the structure of the new coding set works.

ICD-10-CM/PCS will replace ICD-9-CM on Thursday October 1, 2015. Beginning then, all health care providers, health plans, and health care clearinghouses will be required to use the new ICD-10-CM/PCS coding system.

We've made ICD10Data.com more smartphone and tablet friendly - please do not hesitate to use this website in a mobile environment.

Codes

• 2015 ICD-10-CM Diagnosis Codes
• 2015 ICD-10-PCS Procedure Codes

Coding Rules

• Newborn/Neonate Diagnoses (0 years)
• Pediatric Diagnoses (0-17 years)
• Maternity Diagnoses (12-55 years)
• Adult Diagnoses (15-124 years)
• Female Only Diagnoses
• Male Only Diagnoses
• Manifestation Codes
• Present On Admission Exempt Codes
• Codes Questionable As Admission Diagnosis
• Codes Unacceptable As Principal Diagnosis
• Duplicate Codes

Indexes

• 2015 ICD-10-CM Diagnosis Codes Index
• 2015 ICD-10-CM External Cause Index
• 2015 ICD-10-CM Table of Neoplasms
• 2015 ICD-10-CM Table of Drugs

DRG

• Medicare Diagnosis Related Groups

Be sure to keep www.ICD10DATA.com handy -- it's a great FREE resource for RN-Coders and RN-Auditors!

OK! This CMS Agreement with AMA Helps Us "GO TO 10!"

Grace period agreement likely the death knell for another ICD-10 delay

July 8, 2015 | By Dan Bowman

In announcing a joint effort with the American Medical Association to ease the transition to ICD-10 for providers, the Centers for Medicare & Medicaid Services on Monday essentially sounded the death knell for the possibility of a fourth delay.

CMS said that, for the first year after the transition, it will not deny or audit Medicare claims from providers based solely on the specificity of diagnosis codes, as long as the codes on such claims are from the correct family in the new code set. What's more, if Medicare contractors cannot process claims due to problems with ICD-10, CMS will authorize advance payments to physicians.

Additionally, an ICD-10 ombudsman employed by CMS will work to sort through issues as they arise via a "Coordination Center," according to the agency.

While AMA wasn't the only organization opposed to the transition, it certainly was the most vocal. In May, it backed Rep. Ted Poe's proposal to eliminate ICD-10. And last November, then-AMA President Robert Wah joked that the association wanted to freeze ICD-10 in carbonite.

Now, AMA and CMS are seemingly locking arms and singing Kumbaya.

The plan offers a solution similar to legislation floated by Reps. Diane Black (R-Tenn.) and Gary Palmer (R-Ala.), who proposed grace periods of 18 months and two years, respectively. However, the key differentiator, according to American Health Information Management Association Senior Director of Coding Policy and Compliance Sue Bowman, is the requirement that codes stay within certain familial parameters. AHIMA opposed both Congress members' solutions, but offered support for the CMS-AMA collaborative effort, as did both Black and Palmer.

"The other proposals were too open ended," Bowman told FierceHealthIT. "We were concerned about the potential for wildly erroneous data and even fraud and abuse. The other proposals opened the door to say you could put any code on a claim and somehow expect to be paid with no questions asked."

Bowman said the new solution offers some flexibility for providers to learn the system and not have to worry about some of the specificity early on, while still requiring a basic level of accuracy.

"This got to the heart of what the physician community really wanted, which was not too much rigidity during the learning curve period," she said.

While pressure from the AMA and other groups no doubt loomed large, Bowman said the desire to ensure a smooth and successful transition likely was the biggest factor in CMS' decision to move forward with the grace period.

Whatever the case, she hopes that now people will have less anxiety, and will focus more on getting ready for the compliance state.

With AMA, CMS and AHIMA all on the same page, that's probably a safe bet. - Dan (@Dan_Bowman and @FierceHealthIT)

A Physician Roadmap to ICD-10 - 55 Days & Counting!

Written by  Donald Bialek, MD, MPH and Tom Ormondroyd

• http://www.roadto10.org/

  With the sustainable growth rate (SGR) bill now signed into law, it is time for physicians to really focus on their preparations for the upcoming ICD-10 implementation. ICD-10 will affect every aspect of a physician’s practice, including patient encounters, clinical and financial workflow, as well as compensation and reimbursement. It requires more accurate documentation and gives physicians more diagnostic choices to capture new data in order to ensure they are paid for the complex work being performed.

An ICD-10 roadmap can help physicians minimize productivity loss, avoid financial pitfalls, and ensure they receive proper financial and quality credit for the care they provide. Physicians will require a focused education and training plan, tailored to the “need-to-know” aspects of ICD-10. Just as it was unnecessary to use all of the codes in ICD-9, this will certainly be true of ICD-10.

Physicians first should focus on the clinical conditions that they see most frequently, then concentrate on specialty and common co-morbidities of their patients. Attention to clinical documentation is critical. ICD-10 is meant to capture more detail, and it is mandatory that the documentation supports this granularity to ensure accurate reimbursement and the capturing of the true severity of each patient’s illness. Also, getting it right the first time helps avoid time-consuming questions from coders and clinical documentation improvement specialists later in the process. Education is a personal experience, not a one-size-fits-all approach. Educating oneself in ICD-10 strategies varies from person to person, but usually the process takes 3-12 hours. Planning for that time and choosing an approach that fits are both crucial to ICD-10 success.

When beginning ICD-10 education, a physician should have four training goals:

• Focus on large topic areas – ICD-10 has 8-10 core documentation concepts that can be applied to any disease, such as site, specificity, laterality, timing, manifestations, stage, and status.
• Target risk-heavy and high-volume areas – only address gaps in current practice.
• Concentrate on specificity and underlying conditions – document more than the first diagnosis to establish severity of illness and medical necessity.  
• Incorporate electronic medical record (EMR) training to be optimized for ICD-10 with the use of templates, prompts, and automatically incorporated data already in the EMR in the clinical note. Using documentation templates improves physician efficiency and helps the physician be more timely and complete in documenting each visit. 

It is important for physicians to spend time preparing for ICD-10 now in order to avoid repeatedly correcting denied claims or enduring bad outcomes from an audit due to incomplete or inaccurate documentation. A good initial design generally is preferable to trying to repair things after the fact. ICD-10 presents significant changes to the medical coding vocabularies. It is focused on clinical needs so that essential clinical information about each patient can be captured. It is important to ensure that EMRs capture the necessary information to do this.

The ICD-10 transition deadline is just months away, and it is time to address these areas of concern.


About the Authors
Donald Bialek, MD, MPH, is a member of the Precyse Advisory Council. A seasoned expert in the healthcare field, he has been instrumental in bringing clinical and operational perspective to his work in quality, physician engagement, clinical operations, and informatics. 

Tom Ormondroyd is the vice president and general manager of Precyse Learning Solutions and is the creator of Precyse University and Precyse University DNA. He also oversees several business lines, including ICD-10 Consulting and Educational Services. 

ONLY NURSES CAN CODE ICD10 . . . READ THIS!

ICD-10 transition is not just about Oct. 1

by CARL NATALEJUN 24, 2015 - 06:00 AM

  

Many healthcare organizations are focusing on being ready for the ICD-10 changeover on Oct. 1. Just as important is what will come after that.

Productivity losses

This is legend. The fear is that ICD-10 code set is so large and complex that medical coders aren't going to be able to keep up with their current coding output.

ICD-10 opponents like to point to Canada's 40 percent drop in coding productivity after their ICD-10-CA implementation. But they also switched from a paper-based system to PC-based system at the same time. Canadian coders had a lot to learn and get used to.

Whether American coders will face comparable challenges is something we won't know until after Oct. 1. But those challenges could be mitigated by strong ICD-10 training and clinical documentation improvement (CDI) programs. These investments could help preserve medical claim productivity.

After Oct. 1, medical practices could look for other ways to streamline medical coding workflow. Remove inefficiencies. Add automation.

Denials

This is another legend. The American Medical Association (AMA) is predicting denial and rejection rates as high as 20 percent. Which is the basis of their call for an ICD-10 grace period.

Before medical practices panic over that possibility, they need to know their denial statistics now so they can compare what happens to claims after Oct. 1. They need to track:

• Days in accounts receivable by healthcare payer
• Denial rates
• Amount of reimbursements denied
• If reimbursements match the contracted rates

If tracking waits for Oct. 1, medical practices won't know if the numbers reveal problems or business as usual. Weekly tracking could help keep small problems from becoming big ones at the end of the month.

And if tracking spots problems, there needs to be a process to contact healthcare payers for find out what is the status of claims.

ICD-10 denial management starts now. Medical practices need to understand what triggers denials now and what could cause problems with ICD-10 claims. This will help prevent crippling reimbursement delays.

Queries

If physicians aren't documenting at a level that supports ICD-10 specificity, the number of queries from medical coding staff will increase. And that's going to affect productivity for coders and clinicians. To keep the documentation process moving smoothly, medical coders can improve their queries to make them as efficient and useful as possible:

1. Write in clear, concise and precise language
2. Use evidence specific to the case
3. Avoid asking leading questions
4. Include query in the clinical documentation
5. Start using ICD-10 language
6. Avoid writing queries

 Unfortunately these issues will require resources after Oct. 1. That date is not the finish line. Medical practices need to keep running long after the ICD-10 deadline.

Picking the Value-Based Care Path: Is Medicare Risk Right for You?

Written by  Kai Tsai

Last month, the U.S. Department of Health and Human Services (HHS)released an independent evaluation report indicating that the Pioneer accountable care organization (ACO) model has generated more than $384 million in savings to Medicare during its first two performance years. For many, this is the beginning of the emergence of proof that the ACO model just may work – this, in addition to evidence that the Medicare Shared Savings Program (MSSP) ACO model also worked for some, having generated savings for 52 of the total 220 participants.

These results are encouraging, as the Pioneer ACO program was able to save an average of approximately $300 per participating beneficiary annually while still providing for the delivery of high-quality care to patients. But major decisions are on the horizon for the broader ACO landscape: by mid-2015, the first 220 ACOs to participate in the MSSP will decide if they will continue in the program or if they need to head in a different direction.
As providers successfully participating in risk-sharing arrangements stand at this precipice, they should consider not only whether to continue participation in their existing program – they should evaluate whether to expand to more financially rewarding choices. Because Medicare ACOs, both Pioneer and MSSP, already have made significant investments in clinical integration, network development, and redesigned care models, those providers that generated savings in either Medicare ACO model are uniquely poised to add a risk-based Medicare Advantage (MA) contract. And since shared savings measured against a provider's own past performance continuously deflates performance, a MA model will help enhance savings while continuing to increase care quality.
MA risk contracting offers three significant advantages for providers:

• The network is closed, allowing ACOs to focus further on improving quality and reducing costs.
• Patients are attributed as members to physicians, allowing ACOs to develop a patient-provider relationship that supports a comprehensive care model.
• Savings that are generated stay within the risk-bearing entity, which in this case is the ACO.

Healthcare providers all over the country are continuing to assess their ability to implement and deliver value-based care. To determine if they are ready to take on Medicare risk, providers should:

• Conduct a market assessment. Evaluate county benchmarks to understand your base payment rate and compare payments with those that other local MA plans and providers are receiving. Benchmarking MA penetration against national figures also can enable a provider to realize fully the opportunity that exists in the market.
• Establish comparable Medicare ACO and MA financials. While there might always be Medicare beneficiaries who opt for the open care delivery model in fee-for-service, providers should model how quickly fee-for-service beneficiaries might migrate to a MA plan to enhance budget planning, resource allocation, and capability development.
• Conduct an internal capabilities assessment. Quality programs, care models, and information technology infrastructure all should be evaluated to understand if the organization has the right systems in place to further reduce costs and manage care.

Providers considering adding a risk-based MA contract need to evaluate how four factors will impact the organization:

• Geographical county benchmarks will establish a base payment rate based on location. While current Medicare ACO benchmarks are determined by the assigned population's historical claims data, MA benchmarks are driven by county-level MA payment rates.
• Thoughtful, cautious risk adjustment yields the greatest opportunity under MA to increase a provider's revenue. The MA risk adjustment is recalculated each year and compared to the Medicare ACO risk adjustment, which is recalculated following every three-year contract period.
• Medicare leverages data from paid encounters, member satisfaction surveys, and health plan reporting to give plans an overall performance rating. These Star Ratings, which reflect factors such as outcomes and patient experience, determine what plans are eligible for a 5-percent payment bonus.
• Deep MA penetration may be advantageous, as provider practice patterns and behaviors likely already are well-aligned with MA incentives. A competitive MA market can give Medicare ACO leaders confidence that physicians in their market are well-acquainted with coding procedures and quality reporting activities. However, if a Medicare ACO operates in a market with little MA penetration, leaders should identify if there is resistance to managed care as well as consider planning for a longer ramp-up period to educate both healthcare providers and patients on the offering.

When it comes to MA plans, managing well-informed, well-planned risk is not as risky as it seems. There are a wide variety of tools and approaches available to providers that can limit the financial risk of arrangements they enter into – whether MA or others. Most importantly, advances in technology and predictive modeling have evolved to enable providers to apply proven actuarial analyses without maintaining a full staff of actuaries. Visibility into financial risk, and thus the ability to account for it, has never been more available and actionable for providers.
With a range of different health systems already positioned as MA providers, industry experts realize that just about any provider organization can be successful in this transformation. Those providers that move first to take clinical and financial control of their Medicare populations also likely will see a significant competitive advantage in their markets.

About the Author
Kai Tsai is Valence Health's vice president of consulting services and strategic initiatives. With deep expertise in Medicare and senior markets, he's responsible for leading the operations of the company's consulting practice and managing key client relationships, and is a government programs industry leader. Kai earned his master's of health services administration from the University of Michigan.
Contact the Author
information@valencehealth.com