Inpatient Coder
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Position Summary: Reviews inpatient clinical documentation to determine the appropriate assignment of alpha numeric diagnosis/procedure codes and Medicare Severity Diagnosis Related Groups (MS-DRG). Data is classified for internal and external statistical reporting, research, regulatory compliance and reimbursement.
Position Responsibilities:
Key Areas of Responsibility
- Applies strong knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of diagnosis and procedure codes for more complex accounts.
- Analyzes medical records using the Uniform Hospital Discharge Data Set (UHDDS), interprets documentation and assigns proper International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnoses and ICD-10-Procedural Classification System (PCS) operative procedure codes utilizing designated software to included Computer Assisted Coding (CAC) and/or encoder, coding manuals and other reference material.
- Reviews DRG assigned to each record. Enters coded/abstracted information into software, analyzes DRG groupings, and observes for appropriate DRG assignment.
- Reviews high dollar and more complex cases including but not limited to, medical, surgical, behavioral health and IP Rehabilitation.
- Applies IRF-PAI guidelines for IP Rehabilitation coding.
- Adheres to all department coding procedures, policies, guidelines and quality standards.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association/American Association of Procedural Coders and adheres to official coding guidelines.
- Meets revenue cycle goals (Key Performance Indicators (KPIs) and Productivity Standards).
Issue Resolution: Complete on a daily basis cases that have been assigned for review of edits, etc.
Communication:
- Collaborates with clinical documentation specialists (CDS) to determine appropriate DRG assignment for compliance and reimbursement purposes.
- Collaborates with Quality Management and other departments (Billing Registration, etc.) as required.
- Seeks clarification from attending physician in cases where documentation is absent, ambiguous, or contradictory.
Training:
- Assists in training and mentoring new coders to become acclimated to new environment, and understand internal coding policies and procedures
Working Relationships: This position reports to Inpatient Coding Manager