Responsible for coding and abstracting inpatient records of quaternary care hospitals with high acuity needs. This is done using a computerized encoding software and electronic record. This position is responsible for accurately assigning and sequencing diagnoses and procedure codes using ICD 10 CM diagnosis and ICD 10 PCS procedure codes with advice from Coding Clinic and ICD 10 CM, ICD 10 PCS Official Coding Guidelines and other references.
Reviews all documentation from Qualified Medical Providers to assign all significant diagnosis based on guidelines. Additionally, all documentation from nurses must be reviewed, to assign correct codes based on AHA Coding Clinic such as wound care. Coder must understand the reimbursement rules and quality outcomes so diagnoses can be clarified for statistical, research, SOI/ROM severity, best DRG outcome and as well as accurate assignment of present on admission (POA) indicators.
Codes cases utilizing a computerized encoding software system and completes abstraction for clinical data and non-clinical data elements for community and academic hospital sites. This position is responsible for reviewing all documentation in the patient record for accurate and complete code. High dollar cases must be coded within 24 hours. High dollar cases for these coders are typically $500,000 and higher.
Must be able to do a clear and concise query to the MD, when there is conflicting documentation. Must also be able identify and place accounts to the correct status/hold when additional documentation is required for accurate and complete coding.
Collaborate with Clinical Documentation Specialist (CDS) team as part of the clinical documentation validation process to provide the most accurate and complete diagnosis. Work with Clinical Documentation Specialists, as part of the Clinical Documentation improvement team to validate the DRG, SOI/ROM and HCC. Forward queries created by the CDS team to the medical staff to obtain the most accurate DRG. This provides outcomes for the organization as well as accurate reimbursement and benchmarking.
Collaborates with the Coding Quality team when alerted to coding quality issues found via internal and external reviews; implement, with accuracy, coding quality recommendations.
Collaborates with HIM operations as needed to clarify queries and documentation needs for the completion of the medical record.
Verify abstracting of discharge disposition as this often has an impact on the DRG.
Collaborate with quality and CDI to ascertain that charts are at the highest level possible for SOI/ROM based on documentation for critical charts such as mortality cases for benchmarking purposes based on documentation. Query for unclear or conflicting documentation on a pre-bill basis.
Maintains a productivity rate of 100% on a monthly basis and a quality rate of 95% or higher.
Assists in ensuring coding compliance with federal, state, and other regulatory agencies, research cases, government payors and other selected third-party payors.
Licenses & Certifications Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA), or Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA), or Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA), or Degrees Associate's Degree in Health Information Management or related field. Required Functional Experience Typically requires 7 years of experience in ICD-10-CM & ICD-10-PCS progressive inpatient coding experience in an integrated acute care teaching setting with proven competency in lower level inpatient records. Knowledge, Skills & Abilities Knowledge of, but not limited to, current Official Coding Guidelines and methodologies, MS-DRGs, APR-DRGs, the ICD-10-CM/PCS coding systems and conventions. Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results. Advanced knowledge of pharmacology indications for drug usage and related adverse reactions. Knowledge of coding systems and regulatory requirements of Inpatient Prospective Payment System (IPPS). Extensive knowledge with Quality Outcomes, Agency for Healthcare Research and Quality, including Patient Safety Indictors, Hospital Acquired Conditions, and mortality. Proficient with encoder software and other coding applications/tools. Strong communication skills (interpersonal, verbal and written). Strong organizational and analytical thinking skills. Proficient with Microsoft Office applications (Outlook, Word, Excel). Self-motivated and demonstrated capacity to work independently without close supervision. Ability to quickly analyze a situation, problem solve and prioritize. Knowledge of external auditing programs; ex.: Recovery Audit Contractor (RAC), Office of the Inspector General (OIG), third-party payors. Maintains required continuing education credits and certification(s). #Remote
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