What are the responsibilities and job description for the HB HIM Coding Specialist 3 position at St. Charles Health System?
The Hospital Coding Specialist III at St. Charles Health System is responsible for coding/abstracting inpatient records. This position does not directly manage other caregivers, however, may be asked to review and provide feedback on the work of other caregivers.
Essential Functions And Duties
Advanced skills in reading and interpreting documents contained in the medical record to identify and code all relevant ICD-10-CM diagnoses and ICD-10 PCS procedures by utilizing an encoder program, and following National and SCHS coding guidelines, Coding Clinic, and other appropriate coding references and tools to ensure proper code assignment.
Abstracts medical record information in compliance with CMS requirements and SCHS abstracting procedures. Uses available tools to check entries for accuracy. This may include data for clinical studies and quality management activities.
Selects principal diagnoses and procedures in accordance with coding and UHDDS standards, CMS requirements, and prospective payment systems. Ensures that correct MS DRG is assigned for proper hospital reimbursement. Ensures that APR DRG severity of illness and risk of mortality values are accurate for reporting purposes.
Queries physicians for clarification when conflicting or ambiguous information is present by following appropriate SCHS procedures.
Assigns Present on Admission (POA) indicator accurately for each diagnoses coded, per CMS requirements published in official ICD-CM coding guidelines, and if uncertain, query the physician.
Accurately assigns discharge disposition code, paying particular attention to post-transfer program DRGs for proper hospital reimbursement.
Plays an active role with the CDI (Clinical Documentation Improvement) team ensuring chart documentation meets the necessary requirements for accurate coding and reimbursement.
Maintains productivity and quality standards.
Supports the vision, mission, and values of the organization in all respects.
Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients, and guests.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.
May perform additional duties of similar complexity within the organization, as required or assigned.
EDUCATION
Required: High School diploma or GED. Graduate of an AHIMA Accredited Health Information Technology program or certification in a self-study course from AHIMA or AAPC.
Preferred: N/A
Licensure/Certification/Registration
Required: Must possess a valid Registered Health Information Technician (RHIT) certification or one or more of the following: RHIA, CCA, CCS, CCS-P, CPC, COC, CPC-H. This position will require the caregiver to maintain required educational credits (CE) through AHIMA or AAPC.
Preferred: Risk Adjustment Coding (microcredential) or AAPCs Certified Adjustment Coder (CRC). Maintains required education credits (CE) through AHIMA or AAPC.
Experience
Required: Three years of hospital coding experience.
Preferred: Inpatient coding experience. Familiarity with 3M encoder. Familiarity with CAC (computer assisted coding).
Essential Functions And Duties
Advanced skills in reading and interpreting documents contained in the medical record to identify and code all relevant ICD-10-CM diagnoses and ICD-10 PCS procedures by utilizing an encoder program, and following National and SCHS coding guidelines, Coding Clinic, and other appropriate coding references and tools to ensure proper code assignment.
Abstracts medical record information in compliance with CMS requirements and SCHS abstracting procedures. Uses available tools to check entries for accuracy. This may include data for clinical studies and quality management activities.
Selects principal diagnoses and procedures in accordance with coding and UHDDS standards, CMS requirements, and prospective payment systems. Ensures that correct MS DRG is assigned for proper hospital reimbursement. Ensures that APR DRG severity of illness and risk of mortality values are accurate for reporting purposes.
Queries physicians for clarification when conflicting or ambiguous information is present by following appropriate SCHS procedures.
Assigns Present on Admission (POA) indicator accurately for each diagnoses coded, per CMS requirements published in official ICD-CM coding guidelines, and if uncertain, query the physician.
Accurately assigns discharge disposition code, paying particular attention to post-transfer program DRGs for proper hospital reimbursement.
Plays an active role with the CDI (Clinical Documentation Improvement) team ensuring chart documentation meets the necessary requirements for accurate coding and reimbursement.
Maintains productivity and quality standards.
Supports the vision, mission, and values of the organization in all respects.
Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients, and guests.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.
May perform additional duties of similar complexity within the organization, as required or assigned.
EDUCATION
Required: High School diploma or GED. Graduate of an AHIMA Accredited Health Information Technology program or certification in a self-study course from AHIMA or AAPC.
Preferred: N/A
Licensure/Certification/Registration
Required: Must possess a valid Registered Health Information Technician (RHIT) certification or one or more of the following: RHIA, CCA, CCS, CCS-P, CPC, COC, CPC-H. This position will require the caregiver to maintain required educational credits (CE) through AHIMA or AAPC.
Preferred: Risk Adjustment Coding (microcredential) or AAPCs Certified Adjustment Coder (CRC). Maintains required education credits (CE) through AHIMA or AAPC.
Experience
Required: Three years of hospital coding experience.
Preferred: Inpatient coding experience. Familiarity with 3M encoder. Familiarity with CAC (computer assisted coding).