The Lead Inpatient Coder codes and abstracts data elements from patient records according to procedure in a timely manner and maintains workflow and productivity by assigning and reviewing work, answering questions, and resolving problems in the inpatient coding unit. The essential functions listed below are not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.
SCOPE OF WORK: Medical record coding services are to be provided in support of the Patient Administration Department at WRNMMC, Bethesda, Maryland, along with the DiLorenzo Tricare Health Clinic-Pentagon (DTHC-P), and other local Military Treatment Facilities (MTF).
1.2.1. The Contractor shall provide Nationally Certified Medical Coder(s), Certified Coding Specialists (CCS), Certified Coding Specialist(s) Physician Based (CCS-P), Certified Professional Coder (CPC)(s), Registered Health Information Administrator(s) (RHIA), and Registered Health Information Technician(s) (RHIT) to review, code, and abstract medical record data. Coders will assign diagnoses and procedure codes for Inpatient Treatment Records (ITR), Inpatient Professional Services (IPS), Emergency Room (ER), Ambulatory Procedure Visits (APVs), and Outpatient Clinical Encounters. The Contractor shall provide services in Government-supplied Medical Treatment Facilities at the Walter Reed National Military Medical Center, also referred to as (WRNMMC), and DiLorenzo Tricare Health Clinic-Pentagon (DTHC-P). The Contractor shall furnish all labor and materials (such as coding books/references) except as indicated. Performance shall be according to the requirements contained in this work statement. The contractor shall use alternate remote/electronic coding systems to code/abstract medical records for off-site coding support to achieve workload requirements via a secure Virtual Private Network (VPN).
1.2.2. Services required are for certified coding and auditing of inpatient medical records, outpatient medical records (clinic visits), inpatient professional services (rounds), and ambulatory procedure visits. Electronic and hard copy documented medical records will be provided and such documentation can include: provider and allied health personnel progress notes, abbreviated medical records (to include brief summary of chief complaint, history and physical exams, diagnoses, procedures, condition on discharge, etc.), operative and procedure reports, consultations including inpatient consultations, history and physical examinations, laboratory, pathology, radiology and nuclear medicine reports. Coding will involve retrieving hard copy records from the shelves and then re-filing in chronological order once the coding function has been completed.
1.2.3. Contract employees shall apply appropriate coding classification standards and guidelines to medical record documentation for accurate coding, shall resolve medical record documentation deficiencies through healthcare provider query, and shall provide routine feedback to healthcare providers to correct deficiencies. The contract employees shall work as part of a team to perform medical record coding, to research errors or missing documentation, and to interact with the providers, business managers or other Government personnel and contract employees.
1.2.4. Contractor personnel shall participate in all staff orientation and/or Training. Contractor personnel will attend a government-sponsored Initial orientation to familiarize them with the policies and procedures of WRNMMC. Orientation attendance will be scheduled by government agency and may include instruction on automated processing, standard operating procedures, local in-services, quality improvement policies, communications, and occupational exposure to blood borne pathogens, safety programs, etc. In addition, contractors may be directed to attend or complete on-line any Dept of Defense, Army, Navy, or Federal Government seminars, conferences, or courses. The government will provide training on the clinical informational systems to contractor staff.
1.2.5. When the Government systems are not available for use, contract personnel shall refer to the MTF Coding Compliance Plan for technical direction. The plan will outline the duties to perform while the systems are down sothe contract employee may complete their shift. The contractor shall ensure all their personnel have the appropriate resources to provide services when the Government systems are not available.
1.2.6. The Contractor shall comply with all applicable laws, rules and regulations, including but not limited to those included in Section 6 of the PWS.