Medical Coder

JOB SUMMARY

The Inpatient Medical Coder is responsible for assigning diagnosis and procedure codes to the following patient types using ICD-10-CM and ICD-10-PCS or any other designated coding classification system in accordance with coding rules and regulations.

· Low acuity inpatient (OB/NB, acute psych, 1-day stays)

· Inpatient rehab

· Acute psych, including gero-psych

Duties also include resolving coding edits. Abides by the Standards of Ethical Coding as set forth by AHIMA. Abstracting required clinical information from the medical record. Responds to audits and makes necessary changes to coding of accounts based on agreed findings.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Coding and abstracting medical records according to Tenet/Conifer’s quality standards.

· Coding: Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Adheres to Standards of Ethical Coding (AHIMA).

· Abstracting: Reviews medical records to determine accurate required abstracting elements (facility/client specific elements) including appropriate discharge disposition.

Coding Quality: Accurately codes and abstracts clinical information from the medical record, in accordance with established coding quality guidelines.

Coding Labor Productivity: Meets and/or exceeds Tenet/Conifer’s coding productivity guidelines set for each specific patient type.

Professional Development: Stays current with CMS Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM and ICD-10-PCS coding. Attends mandatory coding seminars on annual basis for inpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls.

Communicates and resolves coding issues (lacking documentation, physician queries, missing documentation, second level review, etc.) for timely and appropriate follow-up and resolution.

KNOWLEDGE, SKILLS, ABILITIES

Required:

· Proficient in inpatient diagnosis coding guidelines

· Proficient in ICD-10-PCS code assignment

· Knowledge of MS-DRG and APR DRG classification and reimbursement structures

· Understanding of appropriate level of care orders

· Proficient at writing AHIMA complaint physician queries

· Working knowledge of the Inpatient Prospective Payment System (IPPS)

· Functional knowledge of facility EMR, encoder and other support software

· Works collaboratively with CDI, Quality and other facility leadership

Preferred:

· Adept at comparing documentation, code assignment and charge in the financial system for accuracy and completeness and elevating concerns to the appropriate manager

· Ability to establish and maintain effective working relationships as required by the duties of the position

· Ability to concentrate and accomplish tasks with explicit accuracy

· Ability to use office equipment and automated systems/applications/software at an acceptable level of proficiency

EDUCATION / EXPERIENCE

Required:

· Completion of basic coding course (academic, seminar, workshop or facility-based), including: medical terminology and basic anatomy and physiology

· At least 1 full year of medical coding experience in a live environment (ie, not including training)

Preferred:

· At least 1 full year of medical coding experience in a live environment (ie, not including training)

· Associate or bachelor’s degree in health information management, clinical or allied medical field

· Years of coding experience may be considered in lieu of educational requirements

REQUIRED CERTIFICATIONS/LICENSURE

Required - CIC or CCS

Preferred - One of the above certifications plus RHIT or RHIA