– Full time, permanent, Facility Inpatient Coder
– Responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-10-CM, CPT and HCPCS or any other designated coding classification system in accordance with coding rules and regulations.
– Abides by the Standards of Ethical Coding as set forth by AHIMA.
– Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures.
– Abstracting from medical records to determine accurate required abstracting elements (facility specific) including appropriate discharge disposition.
– Demonstrates ability to achieve accuracy and consistency in the selection of principal and secondary diagnoses (including MCC & CC) and procedures.
– Demonstrates ability to achieve accuracy and consistency in abstracting elements defined by per facility.
– Average coding quality standard of 95% or above accuracy per monitoring period.
– Meets and/or exceeds coding productivity guidelines.
– Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM and CPT coding.
– Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-10-CM and CPT updates) for inpatient and outpatient coding.
– Quarterly review of AHA Coding Clinic.
– Attends Quarterly Coding Updates and all coding conference calls
– Communicates and resolves coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
– Knowledge of MS-DRG classification and reimbursement structures
– Understanding of appropriate level of care orders
– Working knowledge of Value Based Purchasing (VBP)
– Proficient at writing AHIMA complaint physician queries
– Adept at comparing documentation, code assignment and charge in the financial system for accuracy and completeness and elevating concerns to the appropriate manager
– Proficient in researching and responding to Business Office questions and/or question by the payer
– Ability to establish and maintain effective working relationships as required by the duties of the position
– Functional knowledge of facility EMR, encoder and other support software
EDUCATION / EXPERIENCE:
– One to three years experience performing medical record coding in acute care setting required
– Associate or Bachelor's Degree in Health Information, Nursing, or other related field, or formal coding classes completed and passed.
– Years of coding experience would be considered in lieu of educational requirements.
– Required: AHIMA approved credential (RHIA, RHIT, or CCS)
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