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Inpatient Coder III - Medical Coding

Department:  Business Services
Status:  Full Time
Shift:  1st

Reviews clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM, ICD-10-PCS, and/or CPT-4 codes for billing, internal and external reporting, research, and regulatory compliance activities. Resolve error reports associated with the billing processes, identify and report error patterns and when necessary assist in the design and implementation of workflow changes to reduce billing errors. Must meet ongoing productivity and quality metrics as established within the department for each level. The coder may work remotely if minimum technology requirements, productivity, and quality requirements are met and they sign, and adhere to, the Telecommuter Work Agreement.

 

Essential Functions:

 

  • Identifies chargeable items and facility level for emergency department visits, including observation services, and enters them into the billing system.
  • Meet and/or exceed the established quality standard of 95% accuracy rate or better while meeting and/or exceeding established production standards.
  • Utilizes technical coding principles and APC reimbursement expertise to assign appropriate ICD-10-CM and CPT-4 procedures.
  • Assigns codes for diagnoses, treatment and procedures according to the appropriate classification system for Outpatient ancillary and Emergency Department encounters, including modifier assignment.
  • Reviews professional and hospital inpatient and outpatient surgery medical record documentation and properly identifies and assigns ICD-10 CM, and/or CPT-4 codes for all reportable diagnoses and procedures.
  • Determines the correct principal diagnosis, co-morbidities, complications, secondary conditions, and surgical procedures.
  • Assigns MS-DRG o Assigns Present on Admission (POA) indicators o Identifies HAC (Hospital Acquired conditions) and when required, reports through established procedures.
  • Accurately abstracts Discharge Disposition code.
  • Queries physicians per established policy and procedure when documentation is not clear or conflicting.
  • Meet and/or exceed the established quality standard of 95% accuracy rate or better while meeting and/or exceeding established production standards.
  • Keeps abreast of coding guidelines by self-study, assigned education, coding meeting attendance, or related in-services. Participates in internal and external quality review meetings.
  • Performs other duties as assigned.

 

Education, Training, and Experience:

 

Required:

  • High school diploma or equivalent.
  • Five years or greater of progressive inpatient (IP) coding experience in an acute care facility.
  • Credentials to include one or a combination of the following: RHIA, RHIT, and/or CCS.

 

Preferred:

  • Academic or level I or II trauma center experience.
  • Two years of progressive OP diagnostic and emergency room coding experience.

 

Skills or Other Qualifications:

 

Required:

  • Ability to code and maintain corporate/department-specific quality standards and meet productivity standards as documented by the department and organization.
  • Knowledge of medical terminology, anatomy and physiology, disease process, and minor surgical procedures.
  • Knowledge of accepted medical abbreviations and their meanings.
  • Knowledge in the use of specialized references such as the ICD-9-CM and CPT-4 books, medical dictionaries and texts, and medical journals.
  • Must have extensive knowledge of Coding Clinic, CPT Assistant, and all official coding guidelines.
  • Advanced knowledge of hospital information systems, encoders, and other technology to facilitate a successful virtual work environment while maintaining maximum communication and adhering to HIPAA security standards.
  • Advanced knowledge of MS Excel, Word, and Outlook functions.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to all official coding guidelines.
  • Technical skills required to learn and navigate a variety of software systems, troubleshoot computer problems, install periodic updates to software programs, and work efficiently in a virtual environment.
  • Strong written and verbal communication skills.
  • Ability to think/work independently, yet interact positively with a remote team.
  • Advanced problem-solving skills.
  • Familiarity with current healthcare-based technology, coding, and Electronic Health Record (HER).
  • Attention to detail is crucial to this position.

 

Preferred:

  • Knowledgeable in Revenue Cycle department functions relating to Ambulatory Payment Classification (APC) grouping, denials, and edits.

 

License and Certification:

 

Required:

  • See above by Level

 

Preferred:

  • See above by Level

 

Position Reports to the Coding Manager

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