Incumbent provides entry level Clinical inpatient coding support through the Health Information Management department and works in conjunction with the Health Information Management leadership to complete all applicable coding assignments for inpatient admissions from various discharge departments including but not limited to; Postpartum, Newborn, Newborn NICU, Cardiac ICU, Ortho, Nephrology, Neurosciences, etc. For compliance, this position must adhere to CMS’ Official Guidelines for Coding and Reporting.
Job responsibilities include the accurate assignment of ICD-10-CM diagnostic codes and procedural PCS codes by proficiently translating diagnostic statements, physician orders, and other pertinent documentation; leading to coding accuracy and abstracting of pertinent data elements from documentation provided to report and code for reimbursement.
This position may also be responsible for identifying appropriate charges based on documentation and coding guidelines. When documentation or a valid order is incomplete, vague, ambiguous, or missing it is the responsibility of incumbent to work in conjunction with HIM staff to utilize the appropriate physician clarification process to obtain additional information that provides a codeable sign, symptom, or diagnosis and/or physician order. Other responsibilities include:
• Adherence to Health Information Management (HIM) Coding policies.
• Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal, secondary diagnoses and procedures.
• Adherence to The Joint Commission (TJC) and other third party documentation guidelines in an effort to continually improve coding quality and accuracy.
• Responsibility for maintaining coding certification and knowledge referencing current
ICD-10-CM coding guidelines and regulatory changes.
• Contacts the appropriate department or HIM staff member for assistance in obtaining physician clarification of diagnoses.
• Participates in performance improvement initiatives as assigned.
This position must consistently meet or exceed productivity and quality standards as defined by department Leadership.
KNOWLEDGE, SKILLS & ABILITIES
1. Knowledge of Anatomy and Physiology, Disease Pathology, and Medical Terminology.
2. Knowledge of basic coding conventions and use of coding nomenclature consistent with CMS Official Guidelines for Coding and Reporting ICD-10-CM coding.
3. Accurate translation of written diagnostic descriptions to appropriately and accurately assign ICD-10- CM diagnostic codes and procedural PCS codes to obtain optimal reimbursement from all payer types, including Medicare/Medicaid, and private insurance payers.
4. Ability to navigate the Electronic Medical Record to identify appropriate documentation for coding/billing in support of submitted department charges.
5. Knowledge of clinical content standards.
This position does not provide patient care.