Job Summary:
Reviews and evaluateshospital inpatient rehab medical record documentation to assign, sequence, editand/orvalidate the appropriate ICD-10- CMandICD-10- PCScodes.Performs coding and/or code/DRGvalidation across multiple entities. Apply all appropriate ICD-10-CMandPCScodingguidelines as well as IRF PAI guidelines when assigning codes. Adheres toCompany Coding Compliance policies and procedures for the assignment of complete,accurate, timely, and consistent codes for diagnoses and procedures.
Responsibilities
Assigns, sequences, validates, and /or editscodes/ DRGs and abstracted data (e.g., physician, discharge disposition, querytracking) for inpatient records for multiple facilities using ICD-10-CM andICD-10-PCS to include:
o Diagnosis description with appropriate37-digit code assignment with corresponding Present on Admission (POA).
o Procedure description with appropriate7-digit ICD-10-PCScode, date and surgeon
o Admitting Diagnosis.
o Dischargedisposition.
o Where applicable, complete the coding portionof the IRF-PAI.
Maintains or exceeds established accuracy standards.
Maintains or exceeds established productivitystandards.
Utilizes the complete patient medical record documentationincode / DRGassignment , validation, and/or editing of codes/DRGs
Initiates, reviews, and/or edits physician queriesin compliance with Company policy where appropriate.
Reviews all official data quality standards,coding guidelines, Company policies and procedures, and clinical/medicalresources to assure coding knowledge and skills remain current.
Follows all applicable coding guidance in assigning,sequencing, validation, and/or editing of codes/DRGs Meets all education a requirement as stated incurrent Company and HSC policy.
Practice and adhere to the Code of Conduct philosophyand Mission and Value Statement and other duties as assigned.
Education:
College Degree (e.g., Bachelors, Masters,Doctorate) in a Health Sciences field required
Experience:
4+ years of recent inpatient coding/DRGCoding experience strongly preferred
Certificate/License:
CCS/or CIC preferred
Knowledge, Skills andAbilities:
Proficient in ICD-10-CM, ICD-10-PCS, MS-DRGs,APR-DRGs, Present on Admission (POA) assignment, and IRF coding. UnderstandsOfficial Coding Guidelines, CMS regulations, and documentation requirements.
Communicates clearly and professionally withphysicians, CDI specialists, case managers, and other healthcare team membersregarding documentation and coding questions.
Customer Orientation establishes andmaintains long-term customer relationships, building trust and respect byconsistently meeting and exceeding expectations.
Reviews medical records, interprets complexclinical documentation, identifies principal diagnoses and procedures, andapplies coding guidelines accurately.
Initiativeindependently takes promptproactive steps toward problem resolution.
Organizationestablishing courses of actionto ensure that work is completed efficiently; proactively prioritizesassignments and keen ability to multi-task.
Policies& Procedures- articulatesknowledge and understanding of organizational policies, procedures and systems.
PC Skills- demonstrates proficiency inMicrosoft Office applications and others as required.
Maintains high coding accuracy by thoroughlyreviewing documentation, validating code assignments, ensuring correct DRGassignment, and following quality standards.
Performs coding responsibilities with minimalsupervision while maintaining productivity, quality, and compliance standards.
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