HIM Inpatient Coder - Remote

UofL Health - Louisville, KY

Remote - Louisville, KY

About the position

This position is responsible for thorough review of clinical documentation and diagnostic results applicable to extract data and appropriately apply ICD-10-CM/PCS and CPT/HCPCS codes and modifiers for billing and reimbursement, internal and external reporting, research, and regulatory compliance. This position commits to accurate medical coding for the following account types and/or service rendered to patients: Inpatient (IP), observation (OBS), and/or (Ancillary (ANC). Interacts as needed with internal customers to include but not limited to hospital staff, physicians and their offices, and other revenue cycle team members. Actively participates in department and hospital performance initiatives when needed to ensure ULH success.

Responsibilities

• Assign present on admission (POA) value for inpatient diagnoses.
• Adheres to coding daily productivity standard set forth in hospital policy.
• Assist CDMP or CDIS team with query status in a timely manner for inpatient.
• Maintains a productivity log of work performed to be submitted to management daily.
• Capitalizes on opportunities and manages associated coding and coding outcome risks.
• Abstracts selected data items and enters in 3MHDM/360 Encoder software with accuracy.
• Accurately codes primary service (inpatient) as well as a secondary service (Ancillary) when needed.
• Review documentation to verify and, when necessary, correct the patient disposition upon discharge.
• Extract required information from source documentation and enter into encoder and abstracting system.
• Attend continuing education workshops, webinars, etc., for coding compliance and maintenance of CEUs.
• Assigns ICD-10-CM-PCS and/or CPT-4 diagnostic and procedure codes to patient charts with accuracy and attention to detail.
• Accurately codes all inpatient charts using ICD-10-CM/PCS codes and modifiers with an accuracy rate of 95% or higher.
• Demonstrates knowledge of coding conventions, rules and guidelines for multiple classification systems and billing practices to ensure reimbursement.
• Utilize technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-10-CM and/or ICD-10-PCS diagnoses and procedures.
• Identify non-payment conditions or hospital-acquired conditions (HACs) and when required, report through established procedures.
• Work collaboratively with HIM Staff and Clinical Documentation Improvement Specialists (CDIS) to ensure the most accurate and complete documentation to support accurate coding/billing.
• Review appropriate provider documentation to determine principal diagnosis, major or non-major co-morbidities and complications (MCCs and CCs), secondary conditions, severity of illness and risk of mortality (SOI/ROM), hierarchal condition categories (HCC), and surgical procedures.
• Inpatient Coders will accurately code inpatient (IP), observations (OBS), and labor and deliver (L&D) conditions and procedures as documented in the ICD-10-CM and/ or ICD-10 CM/ PCS Official Guidelines for Coding and Reporting.
• Efficiently utilize Coding software and HIMS to abstract required data from patient visits in the appropriate coding assignments and timely billing in accordance with DNFC/DNFB goals and established hospital policy and procedures.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to Official Coding Guidelines and AHA Coding Clinic.
• Resolve all coding edits and error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors.
• Completes other assigned duties as directed by management.

Requirements

• RHIA, RHIT, and/or CCS or CPC-H Certification required.
• Previous experience with 3M encoder software required.
• Knowledge of medical terminology and anatomy and physiology required.
• A minimum of 1 year of auditing experience in coding and/or HIM preferred.
• Experience in working with EMR required. Experience with Cerner PowerChart preferred.
• Three (3) years progressive on-the-job inpatient experience coding with ICD-10-CM, ICD-10-PCS, HCPCS, and CPT-4 in a hospital setting required.
• Knowledge of documentation regulations and/or coding guidelines as they relate to ICD-10-CM/PCS and CPT Coding Regulatory Requirements required.