The Medical Coder-Inpatient DRG (IPDRG) provides high-level technical competency and subject matter expertise in analyzing physician/provider documentation in Inpatient health records to determine the principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures. Assigns appropriate Medicare Severity Diagnosis-Related Groups (MS-DRG), All Patient Refined DRGs (APR), Present on Admission (POA), as well as Severity of Illness (SOI) & Risk of Mortality (ROM) indicators for Inpatient records. Identifies Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI) to ensure accurate hospital reimbursement.
Documentation Review and Code Assignment:
Assigns appropriate code(s) by utilizing coding guidelines established by:
- The Centers for Disease Control (CDC), ICD-CM Official Coding Guidelines for Coding and Reporting, Centers for Medicare/Medicaid Services (CMS) ICD-PCS Official Guidelines for Coding and Reporting
- American Hospital Association (AHA) Coding Clinic for International Classification of Diseases, Clinical Modification
- American Health Information Management Association (AHIMA) Standards of Ethical Coding
- Revenue Excellence/HM coding procedures and guidelines
- Navigates the patient health record and other computer systems/sources to accurately determine diagnosis and procedures codes, MS-DRGs, APR DRGs, and identify HACs and PSIs or other indicators that could impact quality data and hospital reimbursement.
- Codes Inpatient health records utilizing encoder software and consistently uses online tools to support the coding process and references to assign ICD codes, MS-DRG, APR DRGs, POA, SOI & ROM indicators.
- Reviews Inpatient health record documentation, as part of the coding process, to assess the presence of clinical evidence/indicators to support diagnosis code and MS-DRG, APR DRG assignments to potentially decrease denials.
- Works Inpatient claim edits and may code consecutive/combined accounts to comply with the 72-hour rule and other account combine scenarios.
- Adheres to the Inpatient coding quality and productivity standards established by the organization.
- Safeguard patient health information in compliance with HIPAA standards.
Query Management & Follow-Up:
- Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous documentation.
- Utilizes EMR communication tools to track missing documentation or Inpatient queries that require follow-up to facilitate coding in a timely fashion.
HIM Collaboration
- Works with HIM and Patient Financial Services (PFS) teams, when needed, to help resolve billing, claims, denial and appeals issues affecting reimbursement.
Coding Knowledge & Expertise
- Maintains CEUs as appropriate for coding credentials as required by credentialing associations.
- Maintains current knowledge of changes in Inpatient coding and reimbursement guidelines and regulations as well as new applications or settings for Inpatient coding e.g., Hospital at Home.
- Identifies and reports coding and/or EMR workflow issues to their supervisor.
- Exhibits awareness of health record documentation or other coding ethics concerns. Notifies appropriate leadership for assistance, resolution when appropriate.
- Maintains a working knowledge of applicable coding and reimbursement Federal, State and local laws and regulations, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
- Performs abstracting of additional data elements.
QUALIFICATIONS:
Required Qualifications:
- Coding Experience: At least 2 years inpatient DRG Coding experience.
- Education: Bachelor of Science in allied health field.
- Credential/Certification: Active Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC) or Certified Documentation Improvement Practitioner (CDIP)
- RCM Knowledge: Extensive, comprehensive working knowledge of medical terminology, Anatomy and Physiology, diagnostic and procedural coding and MS-DRG, APR DRG assignment. Must be proficient in identifying POA, SOI and ROM indicators for Inpatient records as well as HACs and PSIs to ensure accurate hospital reimbursement. Familiarity with HIPAA regulations.
- Software Knowledge: Proficiency with electronic medical records (EMR) such as Epic, Cerner, or Meditech.
- Excellent verbal and written English communication skills and customer service skills (CEFR level of at least B2 for both verbal and written)
Preferred Qualifications:
Education: Master's degree or credential in business, healthcare, or related field preferred
Licensure: Registered Nurse and with active PHRN or USRN license preferred.
Software Knowledge: Current experience utilizing encoding/grouping software and Computer Assisted Coding (CAC) is preferred. Encoder experience (3M/Solventum, Encoder Pro, Codify) preferred. Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint) . Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint)
RCM Knowledge: Prior experience with US healthcare providers or payers.
