HIM Inpatient Coder II
Provides timely and accurate administrative and clinical data through the accurate assignment of current ICD diagnosis and procedure codes while complying with the regulations and requirements of the Federal Government, State licensing agencies and the Hospital’s policies and procedures. Supports TMCH’s management planning process and ensures appropriate reimbursement for inpatient services.
Assigns the correct ICD codes to each diagnosis and operative procedure substantiated by documentation contained in the medical record.
Responsible for accurately coding inpatient record types.
Follows departmental and current official ICD coding guidelines to ensure consistent and accurate coding of diagnostic and procedural data.
Utilizes the 3M HDM System, CAC (Computer Assisted Coding), Epic, and any other necessary applications for proper coding, ensuring accuracy.
Ensures that the medical staff documents have sufficient information for accurate coding and appropriate reimbursement, requesting clarification from the provider when information is incomplete. Assists physicians, their office staff, quality management and other hospital personnel with coding and DRG questions.
Determines the sequence of diagnoses according to UHDDS (Uniform Hospital Discharge Data Set) standards.
Inputs abstract data and codes into computer to gather administrative and clinical data for distribution to outside regulatory agencies, third party payers, administrative staff and physicians.
Ensures that institutional policies and procedures for maintenance of medical records are followed. Maintains current knowledge of coding principles and guidelines as coding conventions are updated.
Maintains a 95% coding accuracy rate.
Achieves weekly utilization productivity of 95% of standard
Operates a personal computer, calculator, FAX machine, copy machine or related office machinery in performing assigned duties.
Operates word processing equipment to store, edit, format, print and revise letters, memos, statistical tables, reports, forms, labels, and other printed materials.
Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.
Performs related duties as assigned.
EDUCATION: Completion of a 2-year college or technical school curriculum in Health Information Management, or an equivalent combination of relevant education and experience. Preferred is the completion of a 4-year college curriculum in Health Information Management.
EXPERIENCE: Demonstrated knowledge of current ICD diagnosis and procedural coding. Two (2) years of related medical coding experience in an acute care hospital setting.
LICENSURE OR CERTIFICATION: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Certified Professional Coder (CPC2), Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC).
KNOWLEDGE, SKILLS AND ABILITIES:
Knowledge of current ICD codes, UHDDS sequencing, and DRG payment methodologies, including both MS-DRGs and APR-DRGs.
Knowledge of medical terminology.
Skill in the coding of medical information and maintaining databases to ensure accuracy.
Skill in organizing tasks to ensure the timely and accurate coding of information.
Skill in both oral and written communication.
Ability to read, analyze and interpret professional journals, governmental regulations, and coding guidelines.
Ability to follow written and verbal instructions.
Ability to maintain good working relationships and communication with the medical staff, nursing, administration, and other ancillary departments with the hospital.
Ability to perform multiple tasks and ensure completion to meet strict deadlines.