The Clinical Coder reviews, analyzes, and codes documentation for hospital medical records to select and sequence the appropriate ICD-10-CM diagnosis, CPT procedure codes as applicable. This position is responsible for the accurate assignment; abstracting to determine accuracy and completeness of the record, utilizing the 3M Coding Reimbursement to compile data and related work assigned. Coding staff in this position are able to code encounters of multiple specialties, as well as mentor and train other coding levels. This position (utilizing encoder software and online tools and references in the assignment of codes). Consults reference materials to facilitate code assignment. Validates charges by comparing charges with health record documentation as necessary. Understands appropriate link of diagnosis to procedure when applicable. Utilizes retrospective edit tool to address possible coding and/or documentation issues related to submitted diagnosis and procedure information obtained from the health record. Consults with CDI, physicians, or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous information. Collaborates with Revenue Cycle Management teams in resolving billing and utilization issues affecting reimbursement.
• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters, outpatient (OP)/emergency department (ED) or observation short stay.
• Prepares and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures and E&Ms.
• Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.
• Ensures accurate coding by clarifying diagnosis and procedural information through a query process.
• Assigns Present on Admission (POA) value for inpatient diagnoses.
• Assigns an accurate physician name against each service and accurate time and date.
• Interacts with physicians and other areas when additional coding information is needed; example to prevent medical necessity denials.
• Reviews documentation to verify and when necessary, correct the patient disposition upon discharge.
• Maintains the assigned target of production and accuracy of Coding.
• Prioritizes work to ensure timeframe of medical record coding meets regulatory requirements.
• Engages with physicians in Coding Query process and provides training as necessary.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Prepares statistics as requested by the management.
• Assists in any other relevant task that may be assigned
• Manages stressful situations and handles multiple tasks at one time
• Encourages a positive environment for other staff members.
• Collaborates with other members of the team to carry out work smoothly
Accountabilities
• Ensures that codes are assigned correctly and sequenced appropriately as per government and insurance regulation
• Implements strategic procedures and choosing strategies and evaluation methods that provide correct results
Experience :-
Required:
• 2-4 years of relevant progressive experience in a similar role
Desired:
• Experience in a large healthcare facility
Educational Qualification: Required:
• Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare
Desired:
• Master degree or equivalent in Health Information Management or relevant field
