Job Summary:
Performs final, ICD-10-CM diagnosis coding and ICD-10-PCS on Inpatient Encounters. Responsible for capturing MCC, CC and all secondary diagnosis with assignment of the correct DRG based on documentation. Inpatient coders help insure the data integrity of the patient's clinical record. Inpatient coders must be able to assign present on admission indicators appropriately. Inpatient coders are responsible for the abstraction of ADT information at the time of final coding. Inpatient Coders must be able to effectively communicate with the medical staff, other departments, and teammates through queries, email, telephone, teleconference and/or face to face encounters. Certified Coders are responsible for maintaining continuing education hours necessary for current certifications. Coders are expected to research diagnosis and procedure techniques to ensure assignment of the appropriate ICD10 CM and ICD10 PCS codes. Uses EPIC and 3M software to review the electronic medical record and the 3M encoder to code and calculate the billing DRG and assign POA indicators. Inpatient coders are to understand the impact coding makes on quality reporting and have working knowledge of CMS quality programs. Inpatient coders are expected to work cooperatively with other team members. Performs clerical duties as required or as designated by the Director, Manager or Supervisor. Coder will be responsible for adding deficiencies, working claim edits as well as denials.
Performance Expectations: