Inpatient Coding Specialist
2 weeks ago
We are seeking a highly skilled Inpatient Coder to join our team at Kaiser Permanente. As an Inpatient Coder, you will be responsible for accurately coding and abstracting inpatient cases or services from medical record documentation.
You will assign codes and modifiers using the appropriate version of ICD-CM, ICD-PCS, CPT, and HCPCS, as well as other specialty systems as required by diagnostic category. Your work must be performed in accordance with the rules, regulations, and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, ICD-PCS, CPT, and HCPCS code book, CPT Assistant, NCCI Edits, CMS, OSHPD, and Kaiser Permanente's organizational and institutional coding guidelines.
Key Responsibilities:- Reviews medical record documentation to identify diagnoses/procedures to be coded.
- Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
- Codes all appropriate diagnosis and procedures from the medical record using ICD-CM, ICD-PCS, CPT, and HCPCS coding classification systems.
- Responsible for the sequencing of diagnoses and procedures in accordance with guidelines outlined in ICD-CM, ICD-PCS, CPT, Uniform Hospital Discharge Data Set, Medicare regulations, and other appropriate classification systems.
- Determines that the DRG is appropriate for each case and reviews DRG discrepancies to ensure appropriate grouping of each case.
- Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting.
- Corrects data when needed.
- Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS, and regional and local KP policies.
- Ensures the accuracy and integrity of data abstracted and coded based upon medical record documentation prior to data submission or coding completion.
- Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
- Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
- Three years of continuous hospital coding experience within the last five years.
- High School Diploma or GED and demonstrated completion of classes in medical terminology, anatomy, physiology, current ICD-CM, ICD-PCS, and CPT coding conventions, and disease process from an accredited program.
- Certified Coding Specialist OR Registered Health Information Technician OR Registered Health Information Administrator.
- Achieve a minimum score of 75% on the KP Inpatient Coding test.
- Must be able to meet productivity and quality standards established for the position.
- Demonstrated ability to understand the clinical content of a health record and translate to coding.
- Demonstrated knowledge of anatomy, physiology, medical terminology, and disease process to interpret general medical classifications for inpatient services.
- Demonstrated knowledge regarding the review of cases for coding quality and coding compliance.
- Basic knowledge of reimbursement methodologies and conventions and knowledge of rules and guidelines for the appropriate and current coding classifications.
- Ability to communicate with physicians regarding the clarification of diagnoses/procedures and the sequencing of diagnoses.
- Must maintain coding credential and complete the required Continuing Education (CE) units.
- Must abide by the AHIMA and AAPC code of ethics.
- Must be willing to work in a Labor Management Partnership environment.
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