Hospital Based Inpatient Coder III

Utilizing an electronic medical record and computerized encoder, this role assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance, and Health Information Management (HIM) policies and procedures.

Responsibilities

• Maintain strict adherence to patient confidentiality according to MHS standards and regulatory requirements.
• Formulate physician queries for validation of pathological findings.
• Request clinical validation queries for CDI review and follow-up.
• Seek clarification from providers or other designated resources to ensure accurate and complete coding.
• Attend educational meetings and seminars to maintain certification and continuing education requirements.
• Review inpatient coding work queues daily to address coding edits and needed corrections and notify billing as needed.
• Review accounts and perform corrections for internal audits and external denials.
• Review inpatient medical records to assign and sequence all appropriate diagnosis and procedure codes using encoder software and official coding guidelines.
• Review Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) for appropriate code assignment.
• Review and validate accuracy of Admission-Discharge-Transfer (ADT) data fields, including discharge disposition, physicians, procedure dates, and present on admission indicators.
• Perform other duties as requested.
• Meet and maintain Memorial Healthcare System coding quality and productivity standards.
• Submit daily productivity reports to the manager by the defined deadline.

Work Conditions

• Primarily office-based work
• Not eligible for shift differential