CODER INPATIENT

US:NV:Carson City Health Information Management

Full Time

Summary

As senior level coding specialist, assigns compliant, complete and accurate coding MS-DRG's, ICD-10-CM diagnosis codes, ICD-10-CM procedure codes, and Present on Admission (POA) indicators for the hospital inpatient, and LTACH on services based upon the clinical documentation provided within the medical record. Works collaboratively with other members of the Revenue Cycle to complete all essential responsibilities in a timely fashion to meet the quality, utilization, and financial needs of the organization. Ensures complete and accurate abstraction of the medical record data.

Qualifications

Required

• Minimum of one of the following active credentials:
• AHIMA RHIA or RHIT or CCS or AAPC CIC
• Three years of previous inpatient hospital coding experience or two years as a clinical coder 2.

Preferred

• Active AHIMA membership
• Active AAPC membership
• Associate's degree in health information technology from an accredited program.

Essential Functions

• Ensures accurate, timely, and appropriate assignment of MS-DRG's, APR-DRG's, ICD diagnosis codes, ICD procedure codes, CPT, SOI and POA indicators, for the purpose of facilitating billing, internal and external reporting, research, and compliance with regulatory and payer guidelines.
• Keep up to date on best practices for coding and health information management practices.
• Adhere to regulatory (CMS) and other third party payer requirements pertaining to clinical documentation, coding and billing.
• Monitors and reviews regulatory changes that impact clinical documentation and reimbursement requirements to ensure accurate and compliant coding
• Clarify with the appropriate provider all incomplete, ambiguous, and / or conflicting clinical documentation when further specificity is needed for accurate and complete code assignment.
• Identify anatomy and physiology, clinical disease processes, pharmacology, and diagnostic terminology to assign accurate diagnosis and procedure codes. Search appropriate reference materials to obtain current information, guidance, and requirements as needed.
• Abstract accurately from the medical record all defined data elements such as diagnoses, procedures, attending physician, consultants, surgeons, discharge disposition, hospital service, etc.
• Works with other revenue cycle departments in identifying root causes of denials and claim rejections, as they relate to documentation and coding processes.
• Addresses questions or concerns posed by coders, clinicians, or other related departments regarding coding, charging, DRG assignments, APC assignments, modifier application, special projects, and other relevant topics
• Maintains or exceeds the standard level of quality and productivity established
• Assist with special projects as needed and performs related duties as assigned. Ability to multi-task with prioritization.