Inpatient Coder

Job Summary:

This position is responsible for thorough review of clinical documentation and diagnostic results applicable to extract data and appropriately apply ICD-10-CM/PCS and CPT/HCPCS codes and modifiers for billing and reimbursement, internal and external reporting, research, and regulatory compliance.

This position commits to accurate medical coding for the following account types and/or service rendered to patients: Inpatient (IP), observation (OBS), and/or Ancillary (ANC).

Responsibilities include assigning present on admission (POA) value for inpatient diagnoses, adhering to coding daily productivity standard set forth in hospital policy, and assisting CDMP or CDIS team with query status in a timely manner for inpatient.

The ideal candidate will have a strong understanding of medical terminology, anatomy, and physiology, as well as experience with 3M encoder software and EMR systems. Additionally, they will have a minimum of 1 year of auditing experience in coding and/or HIM, and 3 years of progressive on-the-job inpatient experience coding with ICD-10-CM, ICD-10-PCS, HCPCS, and CPT-4 in a hospital setting.

Key Responsibilities:

• Assign present on admission (POA) value for inpatient diagnoses

• Adhere to coding daily productivity standard set forth in hospital policy

• Assist CDMP or CDIS team with query status in a timely manner for inpatient

• Maintain a productivity log of work performed to be submitted to management daily

• Capitalize on opportunities and manage associated coding and coding outcome risks

• Abstract selected data items and enter in 3MHDM/360 Encoder software with accuracy

• Accurately code primary service (inpatient) as well as a secondary service (Ancillary) when needed

• Review documentation to verify and, when necessary, correct the patient disposition upon discharge

• Extract required information from source documentation and enter into encoder and abstracting system

• Attend continuing education workshops, webinars, etc., for coding compliance and maintenance of CEUs

• Assigns ICD-10-CM-PCS and/or CPT-4 diagnostic and procedure codes to patient charts with accuracy and attention to detail

• Accurately codes all inpatient charts using ICD-10-CM/PCS codes and modifiers with an accuracy rate of 95% or higher

• Demonstrates knowledge of coding conventions, rules and guidelines for multiple classification systems and billing practices to ensure reimbursement

• Utilize technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-10-CM and/or ICD-10-PCS diagnoses and procedures

• Identify non-payment conditions or hospital-acquired conditions (HACs) and when required, report through established procedures

Requirements:

• RHIA, RHIT, and/or CCS or CPC-H Certification required

• Previous experience with 3M encoder software required

• Knowledge of medical terminology and anatomy and physiology required

• A minimum of 1 year of auditing experience in coding and/or HIM preferred

• Experience in working with EMR required. Experience with Cerner PowerChart preferred

• Three (3) years progressive on-the-job inpatient experience coding with ICD-10-CM, ICD-10-PCS, HCPCS, and CPT-4 in a hospital setting required

• Knowledge of documentation regulations and/or coding guidelines as they relate to ICD-10-CM/PCS and CPT Coding Regulatory Requirements required

About UofL Health:

UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, Brown Cancer Center, Eye Institute, nearly 200 physician practice locations, and more than 1,000 providers in Louisville and the surrounding counties, including southern Indiana. UofL Health is affiliated with the University of Louisville School of Medicine and is committed to providing patients with access to the most advanced care available, including clinical trials, collaboration on research, and the development of new technologies to save and improve lives.

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