Utilizes technical coding expertise to assign appropriate ICD-10-CM/PCS codes to inpatient visit types. Reviews the medical record thoroughly, utilizing all available documentation to code appropriate diagnoses and procedures. Follows ICD-10-CM Official Guidelines for Coding and Reporting, ICD-10-PCS Official Guidelines for Coding and Reporting, Coding Clinic, interprets coding conventions and instructional notes to select appropriate diagnoses and procedures with a minimum of 95% accuracy. Provides technical expertise to analyze system related changes and participates in testing of software modifications. Identifies opportunities to enhance CAC (computer assisted coding), i.e. notifying IT liaison of documents filing to Default folder, incorrect system assigned codes, etc. Reviews CDS documentation, instructional information and/or queries as part of health record review. Collaborates with CDS when there is a DRG mismatch, missed query opportunity or conflicting documentation within the medical record. Interprets health record documentation using knowledge of anatomy, physiology, clinical disease process, pharmacology, and medical terminology to report appropriate diagnoses and procedures. The quality management plan currently is a combination of current and retrospective review of charts by a designated clinical coder. AA/EOE. Required:
- 3 years of related work experience.
- Requires strong knowledge of ICD-10-CM/PCS nomenclature.
- Strong knowledge of reimbursement drivers: principal dx/pcr selection,
- CC/MCC identification and sequencing rules.
- Strong understanding of MS-DRG/APR-DRG and circumstances that impact SOI/ROM
- RHIA/RHIT with CCS.