Coding Specialist-Inpt

Position Purpose:

The purpose of this coding position is to accurately assign diagnostic and procedural coding relative to Clinical Inpatient, Clinical Outpatient, Emergency Department, Same Day Surgery, Observation, and Ancillary services encounters.  ICD-9-CM/ICD-10-CM and CPT code assignment must be consistent with CMS Official Guidelines, regulatory agencies and hospital specific bylaws and guidelines to ensure appropriate revenue reimbursement.

Nature and Scope:

Incumbent will review and analyze health records to accurately identify relevant diagnoses and procedures and is also responsible for translating signs, symptoms, or diagnoses utilized by healthcare providers into appropriate ICD-9-CM/ICD-10-CM codes.

Incumbent must have skill set to:

·         Select correct code assignment.

·         Select correct method for following inpatient coding groupers edits.

·         Assign accurate present on admission indicators.

·         Utilizing and understanding research reference material and how to apply key elements.

·         Knowledge of discharge disposition and reimbursement outcomes.

To appropriately and accurately translate diagnoses and procedures, interaction with charging departments and healthcare providers may be required.

CPT procedure codes must be also be accurately assigned to Emergency Department accounts and Same Day Surgery accounts. Also, in addition to assigning ICD-9-CM/ICD-10-CM diagnoses codes to Observation accounts, Inpatient Accounts, Infusion Therapy charge codes must also be accurately reviewed and assigned for accurate reimbursement.

Incumbent  must be knowledgeable in Anatomy and Physiology of the human body, Disease Pathology, and Medical Terminology in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures performed. Job responsibilities include diagnostic codes by proficient analysis and translation of diagnostic statements, physician orders, and other pertinent documentation leading to coding accuracy and abstracting of pertinent data elements from documentation provided. When documentation is incomplete, vague, or ambiguous, it is the responsibility of incumbent to work in conjunction with department Leadership to utilize the appropriate physician clarification process to obtain additional information that provides a codeable sign, symptom, or diagnosis and/or physician order.  Other responsibilities include:

·         Adherence to Health Information Management (HIM) Coding policies.

·         Adherence to The Joint Commission (TJC) and other third party documentation guidelines in an effort to continually improve coding quality and accuracy.

·         Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.

·         Responsibility for maintaining coding certification and referencing current ICD-9 coding guidelines and regulatory changes.

·         Contacts the appropriate charging department for assistance in obtaining physician clarification of diagnoses and/or procedures.

·         Participates in performance improvement initiatives as assigned.

This position is integral to the collaboration and teamwork with Clinical Documentation Improvement Department and interacts with health care givers as a team member striving to achieve quality patient care at Renown Health.

The incumbent must consistently meet or exceed productivity and quality standards as defined by the HIM Coding Leadership.  Telecommute is allowed with approval from HIM Management.

KNOWLEDGE, SKILLS & ABILITIES

1.       Knowledge of Anatomy and Physiology, Disease Pathology, Pathophysiology, Pharmacology and Medical Terminology.

2.       Knowledge and specific details of coding conventions and use of coding nomenclature consistent with CMS’  Official Guidelines for Coding and Reporting  ICD-9-CM/ ICD-10-CM coding.

3.       Accurate translation of written diagnostic descriptions to appropriately and accurately assign ICD-9-CM diagnostic codes to obtain optimal reimbursement from all payer types, including Medicare/Medicaid, and private insurance payers.

4.       Knowledge of clinical content standards.

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications:  Requirements - Required and/or Preferred

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English.   Degree in Health Information Management preferred. 

Experience:

A minimum of 2 or more years advanced coding experience for multiple patient types in an inpatient acute care facility is required.   Experience in Trauma Level II coding a plus.

License(s):

None

Certification(s):

CCS and/or RHIT and/or RHIA is required.  

Computer / Typing:

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.