Navigates the patient health record and other computer systems/sources to accurately determine diagnosis and procedures codes, MS-DRGs, APR DRGs, and identify HACs and PSIs or other indicators that could impact quality data and hospital reimbursement.
Codes Inpatient health records utilizing encoder software and consistently uses online tools to support the coding process and references to assign ICD codes, MS-DRG, APR DRGs, POA, SOI & ROM indicators.
Reviews Inpatient health record documentation, as part of the coding process, to assess the presence of clinical evidence/indicators to support diagnosis code and MS-DRG, APR DRG assignments to potentially decrease denials.
Works Inpatient claim edits and may code consecutive/combined accounts to comply with the 72-hour rule and other account combine scenarios.
Adheres to Inpatient coding quality and productivity standards established by Revenue Excellence/HM
MINIMUM QUALIFICATIONS
Completion of an AHIMA-approved coding program or Associate’s degree in Health Information Management or a related field or an equivalent combination of years of education and experience is required. Bachelor’s degree in Health Information Management (HIM) or related healthcare field is preferred.
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) is required.
Three (3) years of current acute care or Inpatient coding experience is required. Extensive, comprehensive working knowledge of medical terminology, Anatomy and Physiology, diagnostic and procedural coding and MS-DRG, APR DRG assignment. Must be proficient on identifying POA, SOI and ROM indicators for Inpatient records as well as HACs and PSIs to ensure accurate hospital reimbursement.
Current experience utilizing encoding/grouping software and Computer Assisted Coding (CAC) is preferred.
Ability to use a standard desktop/laptop, email and other Windows applications, if needed, Internet and web-based training tools preferred.