The Clinical Documentation Specialist reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The clinician is responsible for translating diagnostic phrases utilized by healthcare providers into coded form. The translation process required interaction with the healthcare provider to ensure that the terms have been translated correctly. The coded information that is a product of the coding process is then utilized for reimbursement purposes, in the assessment of clinical care, to support medical research activity and to support the identification of healthcare concerns critical to the public at large. The clinician is charged to assign the appropriate DRG/HHRG after concurrent review of the medical record.
The clinician must have a thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for DRG/HHRG. The clinician must be trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. The clinician works as a part of a coding team to achieve and ensure that there is no coding disagreement with the DRG/HHRG.
This position is challenged to be aware of the continual changes in Federal and State regulations for prospective payment, keep informed of changes in treatment modes and new procedures, and to perform coding when physician documentation is vague or missing.
This position does provide patient care.