Inpatient Coding / Abstraction Specialist Hybrid Work Environment

Qualifications

Required:

• Associate’s degree in health information management or equivalent from two-year college.
• Minimum 3 years coding inpatient records in acute or acute/long term care setting.
• Experience with coding outpatient/clinic records desirable.
• Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician-based (CCS-P), or Certified Professional Coder-Payer (CPC-P), or able to achieve certification within 2 years of hire.
• Ability to read, analyze, interpret ICD-9, ICD-10, CPT, HCPCS and Modifier books.
• Ability to document and follow-up on Discharged Not Final Billed (DNFB) reports and to effectively present information and respond to questions from Administration, Physicians, and committee members.
• Can effectively describe when and how to use modifers on CPT codes to physicians and other healthcare providers.
• Understands denials and how to solve them.
• Must be proficient in Anatomy and Physiology, Medical Terminology, and 3M applications.
• Past experience using 3M HDM report writer a plus.
• Must be familiar with a hybrid medical record and working with an electronic medical record.
• Must have experience with proper DRG assignment.

Preferred:

• Experience with coding outpatient/clinic records.
• Registered Health Information Technician (RHIT) certification is a plus.

Responsibilities

Responsible for the coding and facility charge process for inpatient accounts, may assist from time to time with outpatient coding.

Abstracts clinical information from medical records and assigns appropriate ICD 10 diagnoses and procedure codes as appropriate and CPT modifiers according to coding guidelines and established procedures.

Edits and resolves outstanding edits and denials for assigned case load weekly.

Works in collaboration with others using Coding Guru to ensure proper use of modifier assignment to CPT codes for inpatient and outpatient procedures or services.

Communicates to clinicians to resolve issues.

Follows up with providers for any records which cannot be completed for lack of documentation or clarification.

Distributes coding queries as appropriate.

Provides information/training to clinical staff and providers on changes in coding practices such as ICD-10, CPT and modifiers, appropriate documentation practices, and DRG assignments as needed.

Serves as a resource for all hospital staff with questions related to Inpatient ICD 9/10 coding, CPT modifier and DRG assignments.

Participates in training, updates and knowledge-based review on utilizing the Electronic Medical Record to maximize efficient use for coding.

Maintains knowledge of Inpatient coding practices and procedures.

Maintains knowledge of Federal, State, and JC standards of documentation regulations and guidelines.

Maintains and keeps coding credentials current.