Inpatient Coder 3 Certified / HIM Coding

Coding Specialist

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Position Summary:

Reviews inpatient clinical documentation to determine the appropriate assignment of alpha numeric diagnosis/procedure codes and Medicare Severity Diagnosis Related Groups (MS-DRG). Data is classified for internal and external statistical reporting, research, regulatory compliance and reimbursement.

Codes high dollar and all types of multifaceted accounts which includes, but is not limited to, interventional radiology, interventional cardiology, cardiovascular surgeries, major transplants, neurovascular surgeries, spinal fusions and coding level 1 trauma (multi significant)

Position Responsibilities:

Key Areas of Responsibility

• Applies strong knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of diagnosis and procedure codes for more complex accounts.
• Analyzes medical records using the Uniform Hospital Discharge Data Set (UHDDS), interprets documentation and assigns proper International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnoses and ICD-10-Procedural Classification System (PCS) operative procedure codes utilizing designated software to included Computer Assisted Coding (CAC) and/or encoder, coding manuals and other reference material.
• Reviews DRG assigned to each record. Enters coded/abstracted information into software, analyzes DRG groupings, and observes for appropriate DRG assignment.
• Reviews high dollar and more complex cases including but not limited to, medical, surgical, behavioral health and IP Rehabilitation.
• Applies IRF-PAI guidelines for IP Rehabilitation coding.
• Adheres to all department coding procedures, policies, guidelines and quality standards.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association/American Association of Procedural Coders and adheres to official coding guidelines.
• Meets revenue cycle goals (Key Performance Indicators (KPIs) and Productivity Standards).

Issue Resolution

• Complete on a daily basis cases that have been assigned for review of edits, etc.

Communication

• Collaborates with clinical documentation specialists (CDS) to determine appropriate DRG assignment for compliance and reimbursement purposes.
• Collaborates with Quality Management and other departments (Billing Registration, etc.) as required.
• Seeks clarification from attending physician in cases where documentation is absent, ambiguous, or contradictory.

Training

• Assists in training and mentoring new coders to become acclimated to new environment, and understand internal coding policies and procedures

Working Relationships:

This position reports to Inpatient Coding Manager

Qualifications

Education
Associates Degree or equivalent experience

Experience
Minimum: Two to three years of progressive on-the-job experience in an acute care hospital. Preferred: Two to four years of progressive on-the-job experience in an acute hospital.