Coder – Inpatient. Level III – Certified, Department of Health Information Management (HIM)

Overview

Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM and ICD -10 –PCS codes for billing, internal and external reporting, research and regulatory compliance. Under the direction of the director of Health Information Management, accurately code inpatient conditions and procedures as documented in the medical record using ICD-10 Official Guidelines for Coding. Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors.

Responsibilities

- Utilizing all required electronic applications interprets and abstracts pertinent patient health information from documentation in the medical record. Identifies the principle, secondary diagnosis and procedures including complications and co morbidities. Assigns present on admission (POA) value. All coders are required to continuously maintain the required standards of their level. Level III Must code a minimum of 17 records per a day. All levels must code with the accuracy rate of 92-93 %.

- Be able to identify any discrepancies between the demographic and financial data. When necessary had to forward error cases to the manager, correct the patient disposition upon patient’s discharge.

- Exhibits a high degree of accuracy. Coder sequences the diagnosis and procedures using ICD-10 codes in accordance with the official Coding Guidelines and Hospital’s policy. Abides by Standards of Ethical Coding as set forth by the American Health Information management Association (AHIMA).

- Reviews with the manager when code assignments are unclear or documentation in the record is ambiguous or needs more clarification.

- Inputs all codes and other required data into the clinical information system for accurate DRG assignments. Identifies non-payment conditions (HAC) and when required, report through established procedures.

- Identifies resident/physician responsible for the dictation of the operative reports and the discharge summary and inputs the name into the clinical information system.

- Must maintains Coding credentials by completion of educational programs that provide updated training and skills to allow continued competence in Coding by earning the required number of continuing education units.

- Keeps abreast of coding guidelines and reimbursement reporting requirements. Participates in in-services and other training that is made available. Maintains up-to-date codebooks and references. Brings identified concerns/issues to the supervisor for resolution. Accurately completes in timely manner the tasks assigned by Supervisor

- Interacts in a professional, ethical and courteous manner with patients, visitors, and other Bronx-Lebanon Hospital Center staff. Behaves in a manner consistent with delivering the highest level of patient care and with maintaining and furthering a positive public perception of Bronx-Lebanon Hospital Center and its employees.

- Abstracts from the medical record all required data and completes appropriate forms and applications to comply with NYS DOH, such as SPARCS: birth weight, MI heart rate, W-Y-Codes; reporting requirements for Congenital Malformation Registry.

- Establish and maintain positive relationships with patients, visitors, and other employees. Interacts professionally, courteously, and appropriately with patients, visitors and other employees. Behaves in a manner consistent with maintaining and furthering a positive public perception of Bronx-Lebanon Hospital Center and its employees.

Qualifications

- 2-4 Years Medical Records Coding experience

- CCS Required

- High school grad or equivalent.

- Medical Records Information Systems