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; strives 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)

• Is 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.

• Correctly identifies and applies Present on Admission indicators to all applicable diagnoses according to designated guidelines. Accuracy is important due to the far-reaching impact on reimbursement and quality metrics.

• Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.

• Strives to become fluent in the inpatient coding at all of the UPHS facilities.

• Responsible for continuing education both inside and outside the organization along with tracking Continuing Education credits to maintain professional credentials.

Education or Equivalent Experience:

• High school diploma or GED (Required).
• Bachelor's of Arts or Science in Health Information Management or related field (Preferred).
• Up to 1 year of experience or training in coding inpatient medical records (Required).

Credentials:

• Certified Coding Specialist (Preferred).
• RHIA or RHIT (Preferred).