Coder III Facility HB, Inpatient Coding, Days

Coder III Facility HB, Inpatient Coding 

40 hours per week, day shift

JOB SUMMARY: Responsible for the coding of medical information into the WakeOne medical records abstracting system and for monitoring completion of the coding function through established best practice processes, professional and regulatory coding guidelines. Assigns ICD CM/PCS codes (Inpatient) and ICD CM/CPT codes (Outpatient) as directed for respective encounters.  Reviews and edits associated facility charges as directed for the encounters assigned.  Data reported is used for statistical, financial and billing purposes and to meet licensure requirements.

EDUCATION/EXPERIENCE: Graduation from an accredited medical coding program and two years' experience as an inpatient or ambulatory surgery coder in an acute care facility or demonstrated competency of knowledge base.  Satisfactory completion of college level courses in anatomy, physiology and medical terminology preferred.  EPIC health information system experience preferred. 

LICENSURE, CERTIFICATION, and/or REGISTRATION:  Coding certification CCA, CIC, CPC-H, CPC, CCS, RHIT, or RHIA required.

ESSENTIAL FUNCTIONS:

• Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards
• Applies correct ICD CM/PCS (Inpatient) and ICD CM/CPT codes (Outpatient) guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity.
•  Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded.
• Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy.  Brings identified concerns to Manager Coding for resolution.
• Assigns the MS DRG and MCC/CCs that most appropriately reflects documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department (Inpatient).
• Reviews department-specified reports daily to identify charts that need to be coded based and prioritizes as per department-specific guidelines and within designated timelines.  
• Follows up to ensure that any edits that prevent an account from dropping are corrected within established timelines.
• Produces specific reports on a monthly basis per established parameters.
• Responds to inquiries from Patient Accounts or other departments as requested.  Communicates with Manager when trending request volumes impact productivity.
• Participates in on site and/or external training workshops as opportunities arise; maintains credentials, if applicable, and submits written evidence of maintenance.
• Participates in training other coders.  Acts as a mentor when assigned.
• Collaborates on cases where the final DRG and coded DRG differ, in order to resolve the difference (Inpatient).
• Works with the Health Records Specialists to identify opportunities for MS-DRG optimization when medically indicated (Inpatient).
• Participates in accurate data collection, evaluation and recommendations for process improvements.
• Participates as a member of the Clinical Documentation Management Program
• Assists Managers as requested.