Description

JOB SUMMARY

Hospital Inpatient Coding :

The Hospital Coding Specialist III accurately codes inpatient conditions and procedures as documented in the International Classification of Diseases (ICD) Official Guidelines for Coding and Reporting and in the Uniform Hospital Discharge Data Set (UHDDS) and assignment of the appropriate MS-DRG (Medicare Severity-Diagnosis Related Group) or APR-DRG (All Patients Refined Diagnosis Related Groups) for complex, multi-specialty inpatient services.

This individual understands and applies applicable medical terminology, anatomy and physiology, surgical technology, pharmacology and disease processes.

The Hospital Coding Specialist III reviews professional and hospital inpatient medical record documentation and properly identifies and assigns :

• ICD CM and PCS codes for all reportable diagnoses and procedures. This includes determining the correct principal diagnosis, co-morbidities and complications, secondary conditions, surgical procedures and / or other procedures.
• MS-DRG / APR-DRG
• Present on admission indicators
• HAC (Hospital Acquired conditions) and when required, report through established procedures
• PSI conditions and report through established procedures
• Discharge Disposition code
• Works collaboratively with the Clinical Documentation Improvement Specialists to address documentation concerns and DRG assignments
• Assists in the preparation of responses to DRG validation requests and other third party payer inquiries related to coding and DRG assignments as requested

JOB QUALIFICATIONS

EDUCATION

Preferred / Optional : None

EXPERIENCE

• Minimum Required : Three years of progressive inpatient coding experience in an acute care facility in addition to the following;
• Knowledge of medical terminology, anatomy and physiology, pharmacology, disease process, and surgical procedures
• Knowledge of accepted medical abbreviations and their meanings
• Knowledge in the use of specialized references such as the ICD medical dictionaries and texts, and medical journals
• Must have extensive knowledge of Coding Clinic and all official coding guidelines
• Advanced knowledge of hospital information systems, encoders and other technology to facilitate a successful work environment while maintaining maximum communication and adhering to HIPAA security standards
• Advanced knowledge Microsoft Outlook, Excel and Word functions
• Technical skills required to learn and navigate a variety of software systems and trouble shoot computer problems
• Strong written and verbal communication skills
• Ability to think and work independently, yet interact positively with team
• Advanced problem solving skills
• Attention to detail is crucial to this position

Preferred / Optional : Experience with electronic health record systems. Academic or level I or II trauma experience is a plus.

CERTIFICATIONS / LICENSES

Minimum Required : Active credential of Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) through the American Health Information Management Association (AHIMA) required at the time of hire.

Preferred / Optional : None

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Last updated : 2024-03-29