Job Summary: 

• Perform complex diagnostic and procedural coding for inpatient coding
• Review and analyze the medical record to accurately assign the responsible attending physician and clinical service in accordance with guidelines
• Ensure accurate and timely statistics while supporting the financial stability of the organization
• Ensures compliance with reimbursement requirements including the Prospective Payment System
• Assign appropriate codes in accordance with all appropriate guidelines including the IRF Patient Assessment Instrument (PAI) requirements
• Issue physician queries in response to unclear, ambiguous or conflicting documentation
• Participate in ongoing coding education and support coding accuracy activities
• Collaborates with Clinical Documentation Specialists (CDEs) and members of the medical staff 
• Ensure completeness of documentation in the charts so that appropriate codes, and ultimately the correct Diagnosis-Related Group (DRG), are used
• Responsible for ensuring accuracy and maintaining established quality, productivity standards, and key performance indicators established for 3M 360 CAC for CRS and Direct Code

Skills on Resume: 

• Medical Coding (Hard Skills)
• Record Analysis (Hard Skills)
• Data Accuracy (Hard Skills)
• Reimbursement Compliance (Hard Skills)
• Physician Query (Soft Skills)
• Coding Education (Soft Skills)
• Team Collaboration (Soft Skills)
• Documentation Review (Hard Skills)

Job Summary: 

• Responsible for abstracting and coding inpatient medical records as per ICD-9-CM and ICD-10-CM, UHDDS, and compliance coding guidelines
• Review patient histories, operations, chart reviews, consultations and discharge summaries to support codes selected for billing
• Code and review 22-25 inpatient charts daily with 98% quality
• Query the physician regularly for clarifications in the inpatient medical record document
• Utilize ICD-9-CM and/or ICD-10-CM to select the diagnosis-related group (DRG) assignments for each case
• Review appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures
• Assign the present on admission (POA) value for inpatient diagnoses
• Identify mistakes in reports
• Enter coding information into the electronic billing system
• Research on inpatient coding updates and guidelines

Skills on Resume: 

• Inpatient Coding (Hard Skills)
• Chart Review (Hard Skills)
• DRG Assignment (Hard Skills)
• Physician Query (Soft Skills)
• Error Detection (Hard Skills)
• Billing Entry (Hard Skills)
• Guideline Research (Hard Skills)
• Documentation Analysis (Hard Skills)

Job Summary: 

• Utilizes technical coding expertise to assign appropriate ICD-10-CM and ICD-10-PCS codes to inpatient acute care visit types up to 6 days' length of stay across all Medical and Surgical service lines
• Utilizes expertise in clinical disease process and documentation to assign Present on Admission (POA) values to all secondary diagnoses for quality metrics and reporting
• Thoroughly reviews the provider notes within the health record and the Findings from the Clinical Documentation Nurse in the Clinical Documentation Improvement (CDI) Department, who concurrently reviewed the record and provides their clinical insight on the diagnoses
• Utilizes resources within CAC (Computerized Assisted Coding) software to efficiently review documentation and select or assign ICD-10-CM/PCS codes using autosuggestion or annotation features
• Reviews Discharge Planning and nursing documentation to validate and correct the Discharge Disposition which impacts reimbursement under Medicare’s Post-Acute Transfer Policy
• Utilizes knowledge of MS-DRGs, APR-DRGs, and AHRQ Elixhauser risk adjustment to sequence the appropriate ICD-10-CM codes within the top 24 fields
• Ensure correct reimbursement and NM’s ranking in News and World Report
• Collaborate with CDI on approximately 20% of discharges regarding the final MS or APR DRG and comorbidity diagnoses
• Educates CDI on regulatory guidelines, Coding Clinics and conventions to report appropriate ICD-10-CM diagnoses
• Interprets health record documentation using knowledge of anatomy, physiology, clinical disease process, pharmacology, and medical terminology to determine the Principal Diagnosis, secondary diagnoses and procedures
• Follows the ICD-10-CM Official Guidelines for Coding and Reporting, ICD-10-PCS Official Guidelines for Coding and Reporting, Coding Clinic for ICD-10-CM and ICD-10-PCS, coding conventions and instructional notes to assign the appropriate diagnoses and procedures
• Resolves Nosology Messages/Alerts and Coding Validation Warning/Errors
• Meets established coding productivity and quality standards

Skills on Resume: 

• ICD-10 Coding (Hard Skills)
• POA Assignment (Hard Skills)
• CDI Collaboration (Soft Skills)
• CAC Software (Hard Skills)
• DRG Knowledge (Hard Skills)
• Reimbursement Accuracy (Hard Skills)
• Regulatory Compliance (Hard Skills)
• Clinical Interpretation (Hard Skills)

Job Summary: 

• Assigns ICD-10-CM codes to inpatients' and acute rehab inpatients' medical records
• Ensure maximum reimbursement and a valid database utilizing Uniform Hospital Discharge Data Set (UHDDS) definitions of principal and secondary diagnosis and principles of code assignment
• Assign the appropriate physician name/date to any procedures coded in the Optum Computer Assisted Coding program
• Add the appropriate Present On Admission (POA) indicators to the appropriate ICD-10-CM diagnoses
• Ensures the availability of diagnosis and procedure codes to allow for the timely submission of claims to insurance companies by performing job functions #1 and #2 within defined productivity expectations
• Review and make appropriate changes to the discharge disposition on the inpatient claim
• Assist the Clinical Documentation Specialists in identifying opportunities to query the physician for additional documentation
• Updates the Optum Computer Assisted Coding tool with the Final DRG or with any queries that are submitted
• Work with the Clinical Documentation Specialists on concurrent coding to generate the working Diagnosis-Related Group (DRG), Geometric Mean Length of Stay (GMLOS)
• Provide information to the Coding Sequence (CDS) when a query needs to be generated from a coding or clinical clarity perspective
• Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management
• Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures

Skills on Resume: 

• ICD-10 Coding (Hard Skills)
• UHDDS Knowledge (Hard Skills)
• POA Indicators (Hard Skills)
• Claim Processing (Hard Skills)
• Discharge Review (Hard Skills)
• Physician Query (Soft Skills)
• DRG Assignment (Hard Skills)
• Team Collaboration (Soft Skills)

Job Summary: 

• Interacts and communicates effectively with members of the coding team and HIM, physicians, IT, Patient Access and Business Office
• Participates and provides good feedback during coding section meetings and coding education in-services
• Takes initiative to assist others and shares knowledge with the coding group, business office, physicians and nurses on official coding guidelines
• Responds promptly to internal and external customer requests
• Responds promptly to requests to code or review coded accounts for accuracy
• Initiates queries with physicians to obtain or clarify diagnoses and/or procedures, utilizing the established physician query process
• Responsible for assigning diagnostic and procedural codes to encounters of high complexity
• Maintains and achieves the highest standards of coding quality by assigning accurate ICD-9-CM/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines
• Maintains and achieves department standards of abstracting quality
• Reviewing accurate discharge disposition entered by nursing and correcting to achieve the highest quality of entered data

Skills on Resume: 

• Team Communication (Soft Skills)
• Coding Feedback (Soft Skills)
• Knowledge Sharing (Soft Skills)
• Customer Response (Soft Skills)
• Physician Query (Soft Skills)
• Complex Coding (Hard Skills)
• Data Accuracy (Hard Skills)
• Discharge Review (Hard Skills)

Job Summary: 

• Assigns and enters the physician identification number and procedure date correctly in the medical record abstracting system
• Reviews medical record documentation and abstracts data into the encoder and EPIC/Electronic Health Record
• Determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures
• Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines
• Consistently codes and abstracts at or above departmental standards of productivity while ensuring accuracy of coding
• Supports meeting the organizational goal for Accounts Receivable (AR) associated with uncoded accounts
• Maintains coding timeframes within established departmental standards by ensuring all work items assigned to the coding queues are processed promptly
• Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve
• Displays initiative to improve relative to job function
• Contributes ideas to help improve the quality of coding data and abstracting data

Skills on Resume: 

• Data Abstraction (Hard Skills)
• EHR Systems (Hard Skills)
• Diagnosis Determination (Hard Skills)
• Ethical Compliance (Soft Skills)
• Coding Accuracy (Hard Skills)
• AR Support (Hard Skills)
• Self Evaluation (Soft Skills)
• Quality Improvement (Soft Skills)

Job Summary: 

• Code a variety of patient charts including inpatient, outpatient, Clinic and/or ED
• Accurately assigns DRGs, monitors and audits the assignment of DRG accuracy
• Assists Clinical Documentation Specialist with questions and reviews documentation worksheets for accuracy of documentation and coding
• Works with other areas of the hospital, assisting in review, corrections, and rebills of coded accounts
• Facilitates modifications to clinical nurses to ensure that overall quality and appropriate reimbursement is received for the level of service rendered to all patients with a DRG-based payor (Medicare, Medicaid, BlueCross, FirstCare and self-pay)
• Processes discharges by updating the electronic program to reflect any changes in status, procedures/treatment, and conferring with physicians to finalize diagnoses
• Conducts follow-up reviews of clinical documentation specialists to ensure points of clarification have been recorded in the patient charts
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes
• Assists in screen processes, making referrals, interacting with case managers and Clinical Documentation Specialists to ensure continuity of patient care
• Maintains appropriate non-leading queries post-discharge to physicians
• Educates physicians, case management, charge nurse and other departments 

Skills on Resume: 

• Chart Coding (Hard Skills)
• DRG Accuracy (Hard Skills)
• Documentation Review (Hard Skills)
• Account Correction (Hard Skills)
• Reimbursement Support (Hard Skills)
• Discharge Processing (Hard Skills)
• Physician Education (Soft Skills)
• Care Collaboration (Soft Skills)

Job Summary: 

• Utilizing technical coding principles and APR and/or MS-DRG reimbursement expertise
• Assign appropriate ICD-10-CM diagnoses and procedures, as well as abstract these code assignments according to facility guidelines
• Meet and/or exceed the established IP production standards
• Meet and/or exceed the established quality standard of 95% accuracy rate while meeting and/or exceeding production standards
• Reviews daily/weekly system-generated error reports to correct or complete missing data elements
• Assists in implementing solutions to reduce back-end billing errors 
• Queries physicians appropriately when documentation is not black and white and follows up on queries per facility policy
• Utilizes internal (Atos) and qualified external resources to clarify coding policies, guidelines and “gray areas” while adhering to individual client coding policies 
• 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)
• Correctly abstract the required data per facility specifications
• Responsible for assisting with writing appeals for Diagnosis-Related Group (DRG) denials
• Support the assigned Diagnosis-Related Group (DRG) and to address the clinical documentation utilized in the decision-making process to support the validity of the assigned codes
• Responsible for monitoring and working on accounts that are Discharged Not Final Billed, failed claims, stop bills, and epremis

Skills on Resume: 

• ICD-10 Coding (Hard Skills)
• DRG Expertise (Hard Skills)
• Production Standards (Hard Skills)
• Error Resolution (Hard Skills)
• Physician Query (Soft Skills)
• Policy Compliance (Hard Skills)
• Denial Appeals (Hard Skills)
• Billing Support (Hard Skills)

Job Summary: 

• Analyzes provider documentation to ensure the appropriate ICD-10 Diagnosis codes, CPT/HCPCs Codes, and ICD-10 PCS Codes are assigned accurately based on medical documentation
• Assists billing staff in establishing the medical necessity of charges, claims, and clearinghouse edits
• Provides feedback to the clinical staff on coding issues and reviewing denials
• Provides training to each provider regarding errors identified and corrected
• Obtains necessary clarification of information on the notes and charts by physician query
• Provides weekly trending reports to the designated administrator, regarding coding errors, coding changes, missing information from charts, etc.
• Ensures that all medical records have been signed by the appropriate parties
• Evaluates medical records for documentation consistency and adequacy
• Reviews appropriate medical codes for all diagnoses or services
• Enters and organizes the codes into the management software
• Reviews records for compliance with established third-party reimbursement agencies and special screening criteria
• Assists in coding denials and providing other billing resolutions
• Attends various meetings and professional development programs

Skills on Resume: 

• ICD-10 Coding (Hard Skills)
• Billing Support (Hard Skills)
• Error Feedback (Soft Skills)
• Provider Training (Soft Skills)
• Physician Query (Soft Skills)
• Trend Reporting (Hard Skills)
• Record Evaluation (Hard Skills)
• Denial Management (Hard Skills)

Job Summary: 

• Accurately assigns ICD-10, CPT and/or HCPCS codes as applicable and within the established coding guidelines, rules and regulations
• Inpatient coding of Diagnoses and PCS procedures for concurrent accounts and discharged accounts of a non-complex nature
• Ensures the data integrity of coded patient records by reviewing the medical documentation and validating that the documentation is sufficient to support the assigned codes
• Acts as a resource by researching patient accounts in response to questions and/or errors
• Consistently complies with established department productivity and accuracy standards
• Collaborate with assigned areas to identify query opportunities for documentation improvement
• Communicate with providers for clarification or request additional documentation 
• Works in collaboration with team members and other departments to meet departmental monthly goals which may include one or more of the following: DNFB, Pre-AR, Denials and Claim Edits
• Verifies correct discharge disposition based on medical documentation
• Reviews documentation in inpatient and/or IVR (interventional radiology) medical records, and accurately and completely assigns appropriate diagnostic and procedural ICD-9-CM and ICD-10-CM/ICD-10-PCS or CPT-4 HCPCS codes to the greatest specificity
• Assigns the most accurate DRG/APC
• Abstract demographic and coding information into the information system accurately and completely

Skills on Resume: 

• ICD-10 Coding (Hard Skills)
• PCS Procedures (Hard Skills)
• Data Integrity (Hard Skills)
• Account Research (Hard Skills)
• Productivity Standards (Hard Skills)
• Query Identification (Soft Skills)
• Provider Communication (Soft Skills)
• DRG Assignment (Hard Skills)

Job Summary: 

• Coding of physician documentation for risk adjustment utilizing the current ICD-9 Coding guidelines
• Risk adjustment data validation support
• Provider coding education and interdepartmental coding education support
• Assist with providing education on how to document appropriately at the doctors’ offices 
• Review medical charts electronically using a computer 
• Abstract and code diagnosis and documentation information 
• Research and resolution of coding projects 
• Document requested information from the medical record 
• Determine valid encounters, including legibility and valid signature requirements
• Identify valid face-to-face encounters 
• Perform ongoing analysis of medical record charts for the appropriate coding compliance 
• Attend conference calls to provide information and/or feedback

Skills on Resume: 

• Risk Adjustment (Hard Skills)
• Data Validation (Hard Skills)
• Coding Education (Soft Skills)
• Chart Review (Hard Skills)
• Diagnosis Coding (Hard Skills)
• Project Resolution (Hard Skills)
• Compliance Analysis (Hard Skills)
• Information Sharing (Soft Skills)

Job Summary: 

• Performs chart analysis and assigns ICD-CM and ICD-PCS codes using the client's medical record and the abstraction software
• Compute the final DRG assignment to diagnoses
• Ensure the appropriate coding for billing and reimbursement
• Abstracts and/or reviews necessary patient data
• Ensure data integrity, accurate reimbursement, proper case mix and hospital decision support
• Identifies the need for documentation clarity and works with the Clinical Documentation Improvement (CDI) department
• Review clinical documentation and/or request provider documentation clarification
• Maintains client turnaround time expectations for coding based on discharge date, particularly for high-dollar accounts and long lengths of stay 
• Review documentation to code diagnosis and procedures
• Communicate with physicians to obtain or clarify diagnosis and/or procedures via the query process
• Assign accurate codes utilizing an electronic encoder application in accordance with practice policy and regulatory guidelines
• Perform Peer Reviews of Company Health Information Management coding auditors and coders
• Maintain a minimum accuracy rate of 98% while meeting internal productivity standards set by the company

Skills on Resume: 

• Chart Analysis (Hard Skills)
• ICD Coding (Hard Skills)
• DRG Assignment (Hard Skills)
• Data Integrity (Hard Skills)
• CDI Collaboration (Soft Skills)
• Provider Query (Soft Skills)
• Peer Review (Soft Skills)
• Accuracy Standards (Hard Skills)