Inpatient Coding Specialist CCS: Precise, Impactful Records

The role of a Certified Inpatient Coder at Care New England is to ensure accurate coding and abstracting of all inpatient services, procedures, diagnoses and conditions, working from the appropriate documentation in the medical record. Inpatient services include, but are not limited to cardiac care, intensive care, oncology, behavioral, rehab and multiple other diagnostic group classifications. Classification systems include ICD-10-CM & ICD-10 PCS as well as other specialty systems as required by diagnostic category. A proficient understanding and execution of inpatient coding guidelines to ensure accuracy of coding and maintain records in accordance with accepted medical and legal standards. Adherence and compliance to various regulatory guidelines from CMS, AHA and AMA. Must have at least three (3) years hospital inpatient coding experience. This position requires certification as a Certified Coding Specialist (CCS) and three (3) years of compensatory hospital inpatient coding experience. Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program. Coding certification must be maintained on an annual basis. Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance. Ability to understand the clinical content of a health record, including the most complicated records. Must also be able to communicate with physicians via a query in order to clarify diagnoses, procedures and any other conflicting/ambiguous documentation within the medical record. Strong attention to detail and accuracy is needed. Will abide by the AHIMA coding code of ethics. Must be able to maintain department productivity and accuracy standards. Core Responsibilities Analyze medical records, extracting clinical, pathological, therapeutic and epidemiologic data in accordance with established ICD-10-CM coding principles and guidelines Review medical records to identify appropriate diagnoses, procedures and selection of appropriate DRG. Assigns diagnosis and procedure codes from all documentation including procedure notes, operative notes, consultation notes in the medical record using ICD-10-CM & ICD-10 PCS coding classification systems and independently quality checks own work. Collaborates and communicates closely with CDI department. Interacts with physicians via coding queries to clarify conflicting/ambiguous documentation within the medical record in order to accurately code patient diagnostic and procedural information Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, and CMS, regional and local policy Ensure data is optimally coded for documentation capture, financial reimbursement, care planning, statistics and regulatory reporting Reviews medical records to determine accurate required abstracting elements (facility/client specific elements) including appropriate discharge disposition to ensure accurate reimbursement Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems Demonstrates knowledge of anatomy, physiology pharmacology and pathophysiology to interpret general medical classifications for coding discharge data. Ensures timely record availability by meeting established coding and abstracting CNE productivity and accuracy standards Communicates and resolves coding issues around documentation for appropriate follow-up and education Interacts and communicates with department lead and manager to clarify and accurately document patient diagnostic and procedural information Maintains and complies with policies and procedures for confidentiality of all patient records Performs other related duties as assigned #J-18808-Ljbffr Care New England Health System