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Job Summary
To code medical information into the organization billing/abstracting systems and to complete the coding function through established best practice processes and professional and regulatory coding guidelines.
This position will perform complex Specialty Inpatient coding (i.e. – Cardiology or Neurosurgery, etc.) by assigning International Classification of Diseases (ICD) and International Classification of Diseases-Procedure Coding System (ICD-PCS) codes as well as the Diagnosis Related Groups (DRG) assignment. This position will focus on coding specialty inpatient visits. Abstracts and assigns and verifies codes for Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs), Hospital-Acquired Condition/Patient Safety Indicator (HAC/PSI) and Quality Indicators capture as appropriate through documentation validation. Ensures that each diagnosis present on admission (POA) indicator is assigned appropriately. To code for multiple facilities. Adhere to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely and consistent codes. Data reported by this incumbent is used to meet licensure requirements, is used for statistical purposes, and for financial and billing purposes. Incumbent(s) operate under the general supervision of HIM Coding leadership.
Accountabilities
• Applies ICD and ICD-PCS codes to complex specialty records, including but not limited to Cardiology, Neurosurgery, major traumas, and Neonatal Intensive Care Unit (NICU) records based on review of clinical documentation. Verifies assignment of DRGs, MCC/CCs, Hospital Acquired Conditions (HACs) and Patient Safety Indicators (PSIs) that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures. Selects the optimal principal diagnoses with appropriate POA indicator assignment and sequencing of risk adjustment diagnoses following established guidelines. – 75%
• Review work queues daily to identify charts that need to be coded and prioritizes as per department-specific guidelines and within designated time lines. Follows up on On-hold accounts daily for final coding. – 5%
• Identify and request physician queries following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management (AHIMA) guidelines and established organization policies. Ensures all open queries initiated by Clinical Documentation Specialists have been addressed prior to final coding. – 5%
• Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards. – 5%
• Adheres to department standards for productivity and accuracy. – 6%
• Participates in on site, remote and/or external training workshops and training. Attends and participates in CDI-Coding Task Force and other collaborative training and education with CDI, PFS, Specialty areas and Quality. – 1%
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate coding assignment. – 1%
• Demonstrates continuous learning as evidenced by personally developed reference materials, online publications etc., to stay abreast of new and revised Specialty diagnoses, procedures, guidelines, practices and terminology, for reference and application. – 1%
• Performs other duties as assigned. – 1%
Supervisory/Management Responsibilities
This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
• Associate’s Degree or Coding Certificate through American Health Information Management (AHIMA) or other approved coding certification program.
• 7 years – Coding experience in an acute care or ambulatory setting. Ability to pass internal coding test. Work experience may NOT be substitute for education requirement.
Prior experience with specialty coding preferred; demonstrated high productivity and accuracy.
Required Certifications, Registrations, Licenses
• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC) or other approved coding credential.
Knowledge, Skills or Abilities
• Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
• Ability to apply broad guidelines to specific coding situations, independently utilizing discretion and a significant level of analytic ability.
• Meet set forth Coding Quality and productivity. Strong critical thinking skills.
• Strong collaborative relationships with CDI, PFS and other departments.
• Knowledge of electronic medical records and 3M or Encoder System.
• EPIC health information system experience preferred.
• Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
• Knowledge of MS DRG prospective payment system and severity systems.
• Ability to concentrate for extended periods of time
• Ability to work and make decisions independently.
• Basic computer skills.
Work Shift
Day (United States of America)
Location
Corporate
Facility
7001 Corporate
Department
70017512 HIM Coding
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