Overview

Codes inpatient accounts applying appropriate ICD-10-CM/ICD-10-PCS/CPT-4 codes for hospital reimbursement, mortality & morbidity outcomes, research & statistical and regulatory compliance. Abstracts, codes and assigns necessary demographic and clinical data elements required for inpatient records. Effectively utilizes encoder software to assure appropriate reimbursement and accurate DRG & MSDRG assignment. Completes all work in accordance with defined productivity and quality standards. As necessary, consults or queries the physician for additional information or clarification of diagnoses, co-morbid/secondary conditions, and procedures. Provides physicians education on coding, documentation and medical necessity requirements. Assures optimal ethical reimbursement for coded encounters and assures coding practices fall within established compliance guidelines. Uses concurrent documentation database to accurately reflect queries and updates to DRG cases. Must work collaboratively with Nursing Staff on Concurrent Documentation Improvement Team for severity levels within coding guidelines. Performs other related duties as requested by HIM management.
 

Education

• High School Diploma or equivalent

• Educational coursework in anatomy, physiology, and current coding practices required.
• CCS or CIC required within 1 year of hire

Certification/Licensure

• Certification: CCS or CIC required within 1 year of hire

Experience

• High school diploma
• Coursework in Anatomy, Physiology, and current coding practices
• Coding Certs: Required at time of hire or w/in 1 year of hire—- CCS (AHIMA) or CIC
• Strong communication skills
• Ability to work in a collaborative environment making contributions to a multi-function team