Summary:

Utilizing an electronic medical record and computerized encoder, assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures.

Detailed responsibilities:

• Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedure codes utilizing encoder software and following official coding guidelines. Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) for appropriate code assignment.
• Reviews and validates accuracy of Admission-Discharge-Transfer (ADT) data fields; abstracts discharge disposition, physicians, procedure dates, and present on admission (POA) indicators.
• Reviews appropriate inpatient coding work queues daily to address coding edits and needed corrections and follows procedure to notify billing as needed. Reviews accounts and performs needed correction for internal audits and external denials.
• Formulates physician queries for validation of pathological findings. Requests clinical validation queries for Clinical Documentation Integrity (CDI) review and follow-up. Seeks clarification from providers or other designated resources to ensure accurate and complete coding.
• Meet and maintain Memorial Healthcare System (MHS) coding quality and productivity standards. Submit daily productivity report to manager by defined deadline.
• Attends educational meetings and seminars to maintain certification and continuing education requirements.
• Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements.
• Performs all other duties as requested.

Education and Certification Requirements: High School Diploma or Equivalent (Required) Certified Coding Associate (CCA) - American Health Information Management Association (AHIMA)

Required Work Experience: Three (3) years inpatient coding experience in a hospital setting

Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) is required