The Coding Specialist III at St. Charles Health System is responsible for coding/abstracting inpatient charts. This position does not directly manage any other Caregivers
(May perform additional duties of similar complexity within SCHS as required or assigned)
Read and interpret documents contained in the medical record to identify and code all relevant diagnoses and procedures by utilizing an encoder program, and following National and SCHS coding guidelines, Coding Clinic, and other appropriate coding references and tools to ensure proper code assignment.
Abstract medical record information in compliance with CMS requirements and SCHS abstracting procedures. Use available tools to check entries for accuracy. This may include data for clinical studies and quality management activities.
Select principal diagnoses and procedures in accordance with coding and UHDDS standards, CMS requirements, and prospective payment systems. Ensure that correct MS DRG is assigned for proper hospital reimbursement. Ensure that APR DRG severity of illness and risk of mortality values are accurate for reporting purposes.
Query physicians for clarification when conflicting or ambiguous information is present by following appropriate SCHS procedures.
Assign Present on Admission (POA) indicator accurately for each diagnoses coded, per CMS requirements published in official ICD-CM coding guidelines, and if uncertain, query the physician.
Accurately assign discharge disposition code, paying particular attention to post-transfer program DRGs for proper hospital reimbursement.
Plays an active role with the CDI (Clinical Documentation Improvement) team ensuring chart documentation meets the necessary requirements for accurate coding and reimbursement.
Maintain productivity and quality standards.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
Education: Graduate of an AHIMA Accredited Health Information Technology program or certification in a self-study course from AHIMA or AAPC required.
Licensure/Certification/Registration: Must possess a valid Registered Health Information Technician (RHIT) certification or one or more of the following: RHIA, CCA, CCS, CCS-P, CPC, CPC-H. AHIMA member preferred. This position will require the caregiver to maintain required educational credits (CE) through AHIMA or AAPC. Must have a valid Oregon driver’s license and ability to meet SCHS driving requirements. Ability to travel to all SCHS worksites required.
Experience: Three years of hospital coding experience required. Inpatient coding experience preferred. Familiarity with 3M encoder preferred. Familiarity with CAC (computer assisted coding) preferred.
Expert ability and experience in computer applications, specifically electronic health record systems and MS Office
Personal Protective Equipment: Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.
Knowledge of ICD-10 CM and PCS code assignment.
Knowledge of MS DRG and APR DRG reimbursement methodology.
Knowledge of Present on Admission “POA” assignment.
Knowledge of CPT-4 code assignment.
Knowledge of CCI and MN edits and APC grouping.
Knowledge of modifier and revenue code assignment.
Maintains professional knowledge by attending educational workshops, reviewing professional publications, participating in educational opportunities.
Demonstrates SCHS values of Accountability, Caring and Teamwork in every interaction.
Must have excellent communication skills and ability to interact with a diverse population and professionally represent SCHS.
Ability to effectively interact and communicate with all levels within SCHS and external customers/clients/potential employees.
Strong team working and collaborative skills.
Must have a positive attitude, ability to multi-task, pay close attention to details, and be able to act in a professional manner and demonstrate excellent public relations skills.
Ability to work in a fast paced work environment with frequent interruptions, maintaining the highest level of confidentiality at all times.
Ability to multi-task and work independently.
Attention to detail.
Excellent organizational skills, written and oral communication and customer service skills.