Summary:
Under the general supervision of the Health Information Coding Manager reviews the inpatient medical record to assign appropriate codes in accordance with the ICD-10-CM/PCS Official Guidelines for Coding and Reporting. Determines appropriate MS DRG/APR DRG assignment for optimal classification and accurate and compliant clinical reporting. Identifies and recommends physician queries when documentation in the chart is incomplete ambiguous or unclear. Maintains and meets HIS quality and productivity standards.
Responsibilities:
Enters into a written Telecommuting Agreement with department management. The employee agrees to be accessible by telephone/e-mail within a reasonable time period during the agreed upon work schedule and to formally maintain timely and accurate work and rest period records and to submit such work hours weekly to department management in accordance with Lifespan�s system wide written �Telecommuting� policy.
Reads and comprehends the inpatient medical record identifying all treated diagnoses and procedures reporting the correct code(s) adhering to rules set forth in �Official Coding Guidelines.� Performs coding validation on codes computer-assisted and auto-suggested codes from 3M.
Understands clinical documentation to recognize when a query to the physician is required.
Working knowledge of clinical documentation such as lab results identifying respiratory failure uncontrolled diabetes etc. and ability to perform internet searches when fuller understanding is required to further understand disease processes & medications to treat.
Codes straightforward inpatient medical records such as seen in community hospitals excluding Level 1 trauma cases and complex surgical cases.
Reviews internet videos for full understanding of procedures for coding accuracy.
Ability to navigate the electronic medical record. Ensures the medical record documentation supports the codes selected for the principal diagnosis secondary diagnoses complications co-morbid conditions procedures and discharge disposition. Abides by the �Standards of Ethical Coding� as set forth by the American Health Information Management Association. Enters coded/abstracted information and/or validates codes into the 3M DRG grouper assigning utilizing computer-assisted coding tools. Assigns accurate MS-DRG or APR-DRG through use of the clinical analyzing functions reviewed in compliance with medical record documentation. Adds Present On Admission (POA) indicator to diagnoses. Identifies Hospital Acquired Condition and Patient Safety Indicator codes and forwards to designee. Selects the physician performing procedures ensuring accuracy in the hospital�s billing system. Works closely with Clinical Documentation Specialist for additional clinical review Responds timely to coding validator coding recommendations. Prioritizes high paying records to be completed the day received. Performs concurrent coding for in-house patients requiring interim billing. Continually meets coding productivity quality and accuracy standards.
May be required to code rehabilitation records following the established process.
Consistently meets established productivity standards and accuracy standards.
Follows-up on all bill holds to ensure timely billing and reimbursement. Acts as a resource to physicians and other staff on coding principals and DRG assignments and/or outpatient coding issues.
Refers coding billing and system questions to the coding manager or coding validator. Seeks supervisory assistance only after exhausting own resources by referencing appropriate coding publications and manuals. Assists other coders with help answering questions and providing guidance to entry-level coders.
Keeps abreast of coding guidelines and reimbursement reporting requirements. Maintains credential.
Maintains health information confidentiality by adhering to established organizational and departmental policies and procedures.
Performs related clerical and other duties as assigned.
Other information:
BASIC KNOWLEDGE:
Associate degree required; health information technology preferred. (preferably with RHIT or RHIA) and AHIMA CCS Certified Coding Specialist credential. If associate degree is not in health information technology successful completion of an inpatient coding certification program accredited by AHIMA. or the AAPC credential CIC Certified Inpatient coder. Good writing skills to prepare compliant physician queries. Computer literate; capable of researching internet websites to clarify diseases or procedures. Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process.
EXPERIENCE:
Three to five years inpatient coding experience in a teaching or acute care hospital required with proven ability to understand the clinical content of a health record. Trained in medical terminology anatomy and physiology. Ability to recognize and understand clinical documentation pertinent for coding. Good writing skills to prepare compliant physician queries. Computer literate; capable of research internet websites to clarify diseases or procedures. Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process.
WORKING CONDITIONS:
Reads electronic medical records for the entire workday dual computer monitors. Ability to sit for long periods lift a minimum of 25 pounds bend stoop stretch use step-stools to file records. Ability to work under stressful conditions to maintain accounts receivable days achieving productivity and accuracy.
INDEPENDENT ACTION:
Performs independently within the department�s policies and practices. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required.
SUPERVISORY RESPONSIBILITY:
None.
Corporate Headquarters
Providence Rhode Island
United States
None
(No Timezone Provided)
Summary:
Under the general supervision of the Health Information Coding Manager reviews the inpatient medical record to assign appropriate codes in accordance with the ICD-10-CM/PCS Official Guidelines for Coding and Reporting. Determines appropriate MS DRG/APR DRG assignment for optimal classification and accurate and compliant clinical reporting. Identifies and recommends physician queries when documentation in the chart is incomplete ambiguous or unclear. Maintains and meets HIS quality and productivity standards.
Responsibilities:
Enters into a written Telecommuting Agreement with department management. The employee agrees to be accessible by telephone/e-mail within a reasonable time period during the agreed upon work schedule and to formally maintain timely and accurate work and rest period records and to submit such work hours weekly to department management in accordance with Lifespan�s system wide written �Telecommuting� policy.
Reads and comprehends the inpatient medical record identifying all treated diagnoses and procedures reporting the correct code(s) adhering to rules set forth in �Official Coding Guidelines.� Performs coding validation on codes computer-assisted and auto-suggested codes from 3M.
Understands clinical documentation to recognize when a query to the physician is required.
Working knowledge of clinical documentation such as lab results identifying respiratory failure uncontrolled diabetes etc. and ability to perform internet searches when fuller understanding is required to further understand disease processes & medications to treat.
Codes straightforward inpatient medical records such as seen in community hospitals excluding Level 1 trauma cases and complex surgical cases.
Reviews internet videos for full understanding of procedures for coding accuracy.
Ability to navigate the electronic medical record. Ensures the medical record documentation supports the codes selected for the principal diagnosis secondary diagnoses complications co-morbid conditions procedures and discharge disposition. Abides by the �Standards of Ethical Coding� as set forth by the American Health Information Management Association. Enters coded/abstracted information and/or validates codes into the 3M DRG grouper assigning utilizing computer-assisted coding tools. Assigns accurate MS-DRG or APR-DRG through use of the clinical analyzing functions reviewed in compliance with medical record documentation. Adds Present On Admission (POA) indicator to diagnoses. Identifies Hospital Acquired Condition and Patient Safety Indicator codes and forwards to designee. Selects the physician performing procedures ensuring accuracy in the hospital�s billing system. Works closely with Clinical Documentation Specialist for additional clinical review Responds timely to coding validator coding recommendations. Prioritizes high paying records to be completed the day received. Performs concurrent coding for in-house patients requiring interim billing. Continually meets coding productivity quality and accuracy standards.
May be required to code rehabilitation records following the established process.
Consistently meets established productivity standards and accuracy standards.
Follows-up on all bill holds to ensure timely billing and reimbursement. Acts as a resource to physicians and other staff on coding principals and DRG assignments and/or outpatient coding issues.
Refers coding billing and system questions to the coding manager or coding validator. Seeks supervisory assistance only after exhausting own resources by referencing appropriate coding publications and manuals. Assists other coders with help answering questions and providing guidance to entry-level coders.
Keeps abreast of coding guidelines and reimbursement reporting requirements. Maintains credential.
Maintains health information confidentiality by adhering to established organizational and departmental policies and procedures.
Performs related clerical and other duties as assigned.
Other information:
BASIC KNOWLEDGE:
Associate degree required; health information technology preferred. (preferably with RHIT or RHIA) and AHIMA CCS Certified Coding Specialist credential. If associate degree is not in health information technology successful completion of an inpatient coding certification program accredited by AHIMA. or the AAPC credential CIC Certified Inpatient coder. Good writing skills to prepare compliant physician queries. Computer literate; capable of researching internet websites to clarify diseases or procedures. Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process.
EXPERIENCE:
Three to five years inpatient coding experience in a teaching or acute care hospital required with proven ability to understand the clinical content of a health record. Trained in medical terminology anatomy and physiology. Ability to recognize and understand clinical documentation pertinent for coding. Good writing skills to prepare compliant physician queries. Computer literate; capable of research internet websites to clarify diseases or procedures. Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process.
WORKING CONDITIONS:
Reads electronic medical records for the entire workday dual computer monitors. Ability to sit for long periods lift a minimum of 25 pounds bend stoop stretch use step-stools to file records. Ability to work under stressful conditions to maintain accounts receivable days achieving productivity and accuracy.
INDEPENDENT ACTION:
Performs independently within the department�s policies and practices. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required.
SUPERVISORY RESPONSIBILITY:
None.