Inpatient Coding Specialist
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The Inpatient Coding Specialist performs all coding and abstracting by reviewing medical records and selecting the principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures accurately. Performs analysis of the DRG assigned to produce the highest level of reimbursement to which the facility is legally entitled according to stringent coding and compliance guidelines.
- Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, comorbidities and complications demonstrating 95% accuracy as determined by audits.
- Sequences the diagnoses & procedures to obtain the optimal DRG or APR-DRG assignment and demonstrates 95% accuracy as determined by monthly audits.
- Simultaneously abstracts and enters all coded information into EPIC for timely billing. This includes the correct discharge disposition verified through the CRM notes available in PennChart.
- Demonstrates a consistent level of performance; strives to maintain a steady level of productivity.
- Refers charts that require clarification of vague or unclear documentation for accurate coding and DRG assignment to a Coding Quality Specialist to query the physician for the needed documentation.
- Promptly and accurately assigns Coding Hold reasons to all records that cannot be completed immediately due to:
- Missing Operative Notes
- Missing Pathology Report
- Physician Query Needed
- Death Review
- Discharge Disposition
- Missing Other Reports (Card Cath, EPS, etc)
- Correctly identifies and applies Present on Admission indicators to all applicable diagnoses according to designated guidelines. Accuracy is important due to the far-reaching impact on reimbursement and quality metrics.
- Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.
- Is willing to adjust schedule to complete workload and meet pivotal revenue cycle deadlines when requested by management. Cooperates with departmental work volumes by adjusting work schedule.
- Strives to become fluent in the inpatient coding at all of the UPHS facilities.
- Responsible for continuing education both inside and outside the organization along with tracking Continuing Education credits to maintain professional credentials.
- Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
- Other duties as assigned to support the unit, department, entity, and health system organization
- Previous work experience or training in coding inpatient medical records is required
Licenses, Registrations, and Certifications
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is preferred
- Certified Coding Specialist (CCS) is preferred.
Required Skills and Abilities
- Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease processes is required
- Extensive knowledge of ICD-10-CM and CPT-4 classification systems is required
- Ability to assess, prioritize, and complete multiple tasks in a stressful environment is required
- Familiarity with computerized encoders is preferred
- H.S. Diploma/GED is required
- Bachelor’s Degree in Health Information Management or a related field is preferred
We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
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