Job Description

Must be RHIT or RHIA certified.

Job Summary:

Advanced coding position that requires review of medical record documentation and accurately assigns ICD-10-CM, ICD-10 PCS, as well as assignment of the Medicare Severity Diagnosis Related Group, (MS-DRG) / All Patient Refined - Diagnosis Related Group, (APR-DRG) based on payor classification and abstracts specific data elements for each case in compliance with federal regulations. This position codes all types of inpatient records and follows the Official Guidelines of Coding and Reporting, the American Health Information Management Association, (AHIMA) Coding Ethics, as well as all American Hospital Association, (AHA) Coding Clinics, CMS directives and bulletins, Fiscal intermediary communications. Utilizes 3M 360 in accordance with established workflow. Follows Michigan Medicine policies and procedures and maintains required quality and productivity standards.

Responsibilities:

• Extract, review, and analyze clinical information, identify and abstract all pertinent information and translate data into appropriate codes for hospital billing, POA and PSI indicators, research, statistics, financial planning, compliance and marketing to ensure completeness, accuracy and compliance with established guidelines of all governmental regulatory agencies and third-party payers.
• Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnoses and procedure codes, leading to the assignment of the correct Medicare Severity-Diagnosis Related Group, (MS-DRG) or All Patient Refined Diagnosis Related Group, (APR-DRG.)
• The Inpatient Coding Specialist is responsible for verification of the patient's discharge disposition and to ensure the appropriate present on admission, (POA) indicators are assigned to each code. The assigned codes must support the reason for the visit that is documented by the provider to support the care provided.
• Correctly abstract required data per facility specifications
• Exercise independent judgment on determining cases complexity by utilizing clinical knowledge to understand the etiology, pathology, signs, symptoms, diagnostic studies, treatment modalities and prognosis of diseases and procedures to be coded. Research complex diagnoses and/or procedures as needed to enhance coding knowledge to consistently apply the correct ICD-10-CM and ICD-10-PCS codes
• Captures the correct principal diagnosis, co-existing conditions, and principal procedure for each inpatient admission. Works in collaboration with CDI team to consult with the physicians to clarify or improve documentation for correct coding assignment to ensure correct data reporting and reimbursement and to maintain compliance with Federal and State regulations.
• Responsible for sequencing codes that capture accurate Severity of Illness/Risk of Mortality,
• Interact closely with the Clinical Documentation Specialists and DRG Compliance Auditors to query the medical staff appropriately and professionally to obtain accurate documentation necessary to ensure coding compliance and accuracy.
• Expand job-related knowledge and skills by attending and participating in in-services and staff meetings. Keep abreast of coding guidelines and quarterly AHA Coding Clinic.
• Attends required system, hospital and departmental meetings and educational sessions as established by leadership, as well as completion of required annual learning programs, to ensure continued education and growth.
• Responsible to ensure accuracy and maintain established quality, productivity standards, and key performance indicators

Required Qualifications:

• Associate's degree and registration with the American Health Information Management Association as an RHIT or RHIA or Associate's degree and RHIT/RHIA credential-eligible with successful attainment of the credential within six months of hire.
• Certification must be maintained through continuing education.
• Knowledge of medical terminology, anatomy and physiology, treatment methods, patient care assessment, data collection techniques, and coding classification systems.

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