GENERAL SUMMARY:

Possesses the knowledge and skills to thoroughly review the clinical content of all levels of complexity of Inpatient medical records and assigns appropriate ICD-10-Codes to diagnoses procedures for optimal reimbursement, as well as the knowledge to ensure the coding accurately reflect the severity of illness and risk of mortality for quality reporting. Has knowledge of all other types of coding, including, but not limited to, Outpatient, Outpatient Surgery, and Observation, however the focus of work is complex Inpatient coding.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.
2. *Reviews hospital inpatient medical record documentation and properly identifies and assigns: ICD-10-CM and/or ICD-10-PCS codes for all reportable diagnoses and procedures. This includes determining the correct principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures; MS-DRG, APR-DRG; present on admission (POA) indicators; and hospital acquired conditions.
3. Reviews discharge disposition code for accuracy.
4. *Utilizes technical coding principles and MS-DRG reimbursement expertise to assign ICD-10-CM diagnosis and procedure codes as well as abstracting the assignments according to facility guidelines.
5. *Works as a team member to meets or exceed the established quality standard of 95% accuracy while meeting or exceeding productivity standards set forth by the department leadership.
6. *Maintains a thorough and updated knowledge of Official Coding Guidelines, Medicare Administrator Contractor (MAC) directives, Coding Compliance standards and Local and National Medical Review Policies.
7. Assists in identifying solutions to reduce and resolve back-end coding edits.
8. Queries physicians appropriately as needed when the documentation is not clear and follows up on queries.
9. *Provides education to facility healthcare professionals and medical staff in the use of coding guidelines and practices, proper documentation techniques, and query monitoring to assist with documentation improvement activities.
10. Assists with coding quality review activities for accuracy and compliance.
11. *Mentors and trains new coding staff members.
12. *Works as a team member to ensure all coding is accurate and meets turnaround standards.
13. Adheres to relevant policies, procedures, regulations and expectations of Bryan Medical Center.
14. *Abides by the Code of Ethics and the Standards for Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to all Official Coding Guidelines.
15. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
16. Participates in meetings, committees and department projects as assigned.
17. Performs other related projects and duties as assigned.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of anatomy, physiology, pharmaceuticals, medical terminology, disease process and ICD-10-CM and ICD-10-PCS Coding.
2. Knowledge of computer hardware equipment and software applications relevant to work functions.
3. Ability to communicate effectively both verbally and in writing.
4. Ability to meet high standards for work accuracy and productivity.
5. Ability to mentor and train other personnel in coding practices and proper documentation techniques.
6. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.
7. Ability to problem solve and engage independent critical thinking skills.
8. Ability to maintain confidentiality relevant to sensitive information.
9. Ability to prioritize work demands and work with minimal supervision.
10. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Associate Degree or higher required. Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS) required. Minimum of two (2) years of inpatient coding experience in a medical environment required.