HIM Inpatient Coding Specialist I

Responsibilities

• Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, co-morbidities and complications demonstrating 95% accuracy as determined by audits.
• Sequences the diagnoses & procedures to obtain the optimal DRG or APR-DRG assignment and demonstrates 95% accuracy as determined by monthly audits.
• Simultaneously abstracts and enters all coded information into EPIC for timely billing.
• This includes the correct discharge disposition verified through the CRM notes available in PennChart.
• Demonstrates a consistent level of performance striving to maintain a steady level of productivity according to the following guidelines:
• HUP - Average of 7.5-11.5 inpatient records coded daily
• PPMC - Average of 7.5-11.5 inpatient records coded daily
• PAH - Average of 15 inpatient med/surg charts coded daily
• Refers charts that require clarification of vague or unclear documentation for accurate coding and DRG assignment to a Coding Quality Specialist to query the physician for the needed documentation.
• Promptly and accurately assigns Coding Hold reasons to all records that cannot be completed immediately due to: Missing Operative Notes, Missing Pathology Report, Physician Query Needed, Death Review, Discharge Disposition, Missing Other Reports (Card Cath, EPS, etc).
• Correctly identifies and applies Present on Admission indicators to all applicable diagnoses according to designated guidelines.
• Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.
• Willing to adjust schedule to complete workload and meet pivotal revenue cycle deadlines when requested by management.
• Cooperates with departmental work volumes by adjusting work schedule.
• Strives to become fluent in the inpatient coding at all of the UPHS facilities.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures.

Qualifications

• RHIA or RHIT. (Preferred)
• Certified Coding Specialist - CCS (AHIMA). (Required)
• H.S. Diploma/GED. (Required)
• Previous work experience or training in coding inpatient medical records. (Required)
• Bachelor's degree. (Preferred)