SUMMARY: Requires superior knowledge of and skill in applying International Classification of Diseases and Procedures (ICD), and Current Procedural Terminology (CPT) code sets and associated Medicare/Medicaid rules and guidelines. Reviews and interprets patient medical record documentation to identify pertinent diagnoses and procedures and assigns ICD-9-CM, ICD-10-CM/PCS and CPT 4 codes accurately and timely to the highest level of specificity based upon physician documentation for inpatient, observation and outpatient ambulatory procedures/treatment room records. Validates the coded data to one or more Diagnosis Related Groupers (DRG) validates the Present on Admission (POA) indicators for accuracy and identifies and reports hospital acquired conditions (HACs). Primarily codes more complex and difficult inpatient medical records. Identifies and abstracts specified information from the patient medical record and enters data into the medical record abstract data base system for billing and use in all types of CCHCS reporting. Performs extended length of stay coding for interim cycle billing. May perform and facilitate concurrent inpatient coding in order to establish a working DRG and reviews for documentation opportunities and queries with CDIS to clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time. Assists with coding outpatient surgery, observation outpatient ancillary clinic, specialty clinic and emergency room record visits as necessary. Minimum expected accuracy rate for all coding & DRG assignments is 95% or above. Communicates with physicians and other providers regarding documentation requirements and collaborates with Clinical Documentation Specialists on patient cases regarding documentation needs and requirements, and coding and DRG assignment accuracy. Maintains current knowledge of coding, DRG and documentation changes, rules and guidelines.
QUALIFICATIONS: RHIA, RHIT or CCS with two (2) year minimum current full-time current and continuous ICD-9-CM hospital inpatient medical record prospective payment, observation and outpatient surgery coding experience with DRG assignment and CPT-4 outpatient coding and abstracting experience required. Pediatric coding experience highly desired. ICD-10-CM/PCS training completed and proficient by July 1, 2014 required. Technically competent and fluent knowledge in navigation of electronic medical record applications, automated encoders, and other software applications and hardware required for job role required. Experience using Microsoft Office Excel and Word highly desired. Ability to work well independently and productively with minimal guidance and without direct supervision. Must be highly detail oriented, have the ability to remain focused with good organization, interpersonal and communication skills. Ability to maintain confidentiality. Goal oriented, flexible and energetic. Demonstrates superior coding skills, and critical thinking skills. Ability to solve problems appropriately using job knowledge and current policies and procedures. Demonstrated coding knowledge and proficiency is required through on-site evaluation prior to hire. Required to provide current American Health Information Management Association (AHIMA) continuing education certification records.