DHR Health - US:TX:McAllen - Days
Summary POSITION SUMMARY The Inpatient coder reviews and analyzes documentation in the medical record for inpatient visits to ensure accuracy of diagnosis and procedure codes. Coder finalizes the coding and abstracting of the medical record according to ICD-10-CM/PCS, CPT, and HCPCS coding conventions and guidelines supported by the clinical documentation in the medical record. Coder analyzes diagnosis and procedure codes concurrently assigned by Clinical Documentation Specialists. The Inpatient Coder assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Sequence the diagnoses and procedures using official coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges. Resolve Inpatient billing edits. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
POSITION EDUCATION / QUALIFICATIONS RHIA, RHIT, CCS or CIC required. Three to five years hospital experience required.
JOB KNOWLEDGE / EXPERIENCE Experience and/or advanced training in medical coding (MS/APR DRG's, ICD-10-CM, CPT, HCPCS, ect...),
Must have extensive knowledge of medical terminology, anatomy and physiology, knowledge of pharmacology and all major diseases
Requires reasoning ability and good independent judgment.
Critical thinking skills are a must. Must have strong interpersonal skills and the ability to multi-task
3M CRS software experienced preferred
Requires good communication and organizational skills
Must have an understanding of laws and ethics related to health insurance, medical billing and the health insurance
Portability and Accountability Act (HIPPA)
Requires working with minimal to moderate interruptions.
Must complete CE hours annually, according to certification requirements Professional coding and billing experience a plus
Responsibilities POSITION RESPONSIBILITIES Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
Accurately codes all inpatient diagnoses and procedures according to ICD-10-CM/PCS, CPT and HCPCS coding conventions and guidelines.
Follows the AHIMA Standards of Ethical Coding to adhere to Coding Compliance guidelines.
References ICD-10-CM/PCS, CPT, and HCPCS Level II code books as needed.
Accurately attach HCPCS level I and level II modifiers when appropriate
Utilizes 3M Coding references daily for final coding
Utilizes computerized 3M Coding Software.
Meets quality standards of having 95% of charts coded accurately.
Maintains a good working relationship within the department, other departments and medical staff
Coded all available records in a timely manner.
Queries physicians for clarification when ambiguous or incomplete information is present.
Communicates with Coding Manager to solve problems and to clarify coding issues.
Attends workshops, seminars or conferences that pertain to position and that fulfill CE hour requirements
Reviews Coding Clinic updates and continuing education periodicals in a timely manner
Maintain ongoing education to stay abreast of updates in coding conventions and practices
Assists the business office with clearing reimbursement and denial issues
Clears Aeos in a timely manner
Notify HIM staff of incomplete or un-scanned records through the tickler system
Adheres to the Health Information Management Policies and Procedures for coding.
Adheres to the Coding Compliance Plan.
In case of any inaccuracies or discrepancies in the medical record, then it is his or her responsibility to report the matter to the appropriate department so that the necessary corrections can be made
Maintains confidentiality and safeguards all patient related information
Ability to train and mentor junior staff members
Performs Peer review and internal audits
Performs other duties as assigned
Other information LINES OF REPSONSIBILITIES:
(Chain-of-command)
1. (Director)
CUSTOMER SERVICE Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.
AGE SPECIFIC Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age.
AMERICANS WITH DISABILITIES ACT: (ADA) A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.
Light/moderate lifting up to 20 lbs, from the floor to shoulder height.
Yes
Kneeling
Yes
Must be able to assist other employees with lifting more than 20 lbs.
Yes
Walking
Yes
Light/moderate carrying up to 20 lbs.
Yes
Standing/Squatting
Yes
Straight pulling
Yes
Sitting
Yes
Pulling hand over hand
Yes
Pushing
Yes
Repeated bending
Yes
Stooping/Bending
Yes
Reaching above shoulder
Yes
Climbing Stairs
Yes
Simple grasping
Yes
Climbing Ladders
No
Dual simultaneous grasping
Yes
Depth Perceptions needed
Yes
Ability to see
Yes
Identify Colors
Yes
Operating office equipment
Yes
Twisting
Yes
Operating mechanical equipment
Yes
Crawling
No
Ability to read and write
Yes
Ability to Count
Yes
Ability to hear verbal communication without aid
Yes
Operating Personal Vehicle
Yes
Ability to comprehend written/verbal communication
Yes
Other: Ability to deal with stress
Yes
OSHA Category
III
B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.
C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.
D. Aptitudes: HIGH 1 2 3 4 5 6 LOW
Intelligence: General learning ability: The ability to "catch on" or understand instructions and underlying principles. Ability to reason and make judgments. 3
Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3
Numerical: Ability to perform arithmetic operations quickly and accurately. 2
Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to "visualize" objects or two or three dimensions, or to think visually of geometric forms. 2
Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3
Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2
Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3
Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3
Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3
Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3
Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3
I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.
If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.
Employee Signature: ________________________________ Date: ____________________
Transfer/Hire Date Effective: ________________________.
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