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Utilizing an electronic medical record and computerized encoder, assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures.
Job Responsibility:
Assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures
Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements
Formulates physician queries for validation of pathological findings
Requests clinical validation queries for Clinical Documentation Integrity (CDI) review and follow-up
Seeks clarification from providers or other designated resources to ensure accurate and complete coding
Attends educational meetings and seminars to maintain certification and continuing education requirements
Reviews appropriate inpatient coding work queues daily to address coding edits and needed corrections and follows procedure to notify billing as needed
Reviews accounts and performs needed correction for internal audits and external denials
Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedure codes utilizing encoder software and following official coding guidelines
Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) for appropriate code assignment
Reviews and validates accuracy of Admission-Discharge-Transfer (ADT) data fields
Abstracts discharge disposition, physicians, procedure dates, and present on admission (POA) indicators
Performs all other duties as requested
Meet and maintain Memorial Healthcare System (MHS) coding quality and productivity standards
Submit daily productivity report to manager by defined deadline
Requirements:
High School Diploma or Equivalent
Certified Coding Associate (CCA) - American Health Information Management Association (AHIMA)
Three (3) years inpatient coding experience in a hospital setting or a graduate of the MHS coder intern program
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS)
Proficient in basic computer skills and ability to utilize a computerized encoder and electronic medical record system
Requires critical thinking skills, effective communication skills, decisive judgment and the ability to work with minimal supervision
Must be able to work in a stressful environment and take appropriate action