Certified Medical Coder KRA/KPI

Key Responsibility Areas (KRA) & Key Performance Indicators (KPI) for Certified Medical Coder

1. Coding Accuracy

KRA: Ensuring accurate assignment of medical codes for billing and reimbursement purposes.

Short Description: Precision in assigning medical codes.

• KPI 1: Coding Error Rate
• KPI 2: Claim Rejection Rate
• KPI 3: Audit Findings Rate
• KPI 4: Accuracy in DRG Assignment

2. Timely Billing

KRA: Submitting claims promptly to facilitate timely reimbursement.

Short Description: Timeliness in claim submission.

• KPI 1: Average Billing Cycle Time
• KPI 2: Percentage of Claims Submitted Within 48 Hours
• KPI 3: Rejection Resolution Time
• KPI 4: Days Sales Outstanding (DSO)

3. Compliance Adherence

KRA: Ensuring compliance with coding guidelines and regulations.

Short Description: Adherence to coding standards.

• KPI 1: Compliance Audit Results
• KPI 2: Training Completion Rate on Regulatory Updates
• KPI 3: Accuracy in ICD-10-CM/PCS Coding
• KPI 4: Adherence to HIPAA Guidelines

4. Productivity and Efficiency

KRA: Maintaining high productivity levels while ensuring quality.

Short Description: Efficient and effective coding processes.

• KPI 1: Average Coding Cases Completed Per Day
• KPI 2: Time Spent on Average on Each Case
• KPI 3: Rate of Coding Backlogs
• KPI 4: Utilization of Encoder Software

5. Denial Management

KRA: Analyzing and resolving claim denials to minimize revenue loss.

Short Description: Effective denial resolution strategies.

• KPI 1: Denial Rate Reduction
• KPI 2: Recovery Rate of Denied Claims
• KPI 3: Denial Trends Analysis
• KPI 4: Appeals Success Rate

6. Continuous Learning and Development

KRA: Engaging in ongoing education to stay updated on coding changes.

Short Description: Commitment to professional growth.

• KPI 1: Participation in Continuing Education Programs
• KPI 2: Certification Renewal Rate
• KPI 3: Performance in Coding Competency Assessments
• KPI 4: Implementation of Learnings in Practice

7. Quality Assurance

KRA: Implementing quality control measures to ensure coding accuracy.

Short Description: Focus on maintaining high-quality standards.

• KPI 1: Internal Quality Review Scores
• KPI 2: Peer Review Feedback Incorporation Rate
• KPI 3: Identification and Resolution of Coding Discrepancies
• KPI 4: Adherence to AHA Coding Clinic Guidelines

8. Team Collaboration

KRA: Collaborating effectively with healthcare providers and billing teams.

Short Description: Building strong cross-functional relationships.

• KPI 1: Communication Effectiveness with Providers
• KPI 2: Resolution Time for Coding Queries
• KPI 3: Teamwork Ratings from Colleagues
• KPI 4: Interdepartmental Coordination Efficiency

9. Revenue Optimization

KRA: Identifying opportunities to maximize revenue through accurate coding.

Short Description: Focus on revenue enhancement strategies.

• KPI 1: Increase in Average Reimbursement Per Claim
• KPI 2: Revenue Recovery Rate from Previously Denied Claims
• KPI 3: Coding Contribution to Revenue Growth
• KPI 4: Identification of Undercoding/Overcoding Instances

10. Data Analysis and Reporting

KRA: Analyzing coding data to generate insightful reports for performance evaluation.

Short Description: Utilization of data for informed decision-making.

• KPI 1: Timeliness of Monthly Reports Generation
• KPI 2: Accuracy of Code Utilization Reports
• KPI 3: Utilization Rate of Data Analytics Tools
• KPI 4: Actionable Insights Derived from Data Analysis