Review EHR documentation and assign applicable ICD-10 codes. Assign the discharge disposition status code, and abstract data elements using the 3M 360 database and encoder. Query physicians as approprite when clarification is needed on documentation. Depending on need may focus on in-patient (including sequencing ICD-10 codes for the approrpiate MS-DRG and capturing all reportable diagnoses including those impacting the overall APR-DRG and severity/ mortality scores) or outpatient (including posting/correcting applicable charges, and modifier application) coding.
1. Assign ICD-10-CM/PCS, CPT codes adhering to Official Coding Guidelines, AHA Coding Clinic, and payer specific guidance.
2. Query physicians and providers when documentation needs clarification. 3. Abstract required data elements within the 3M database.
4. Maintains and exhibits a current knowledge of profession and completes required continuing education.
5. Maintain established quality benchmarks for DRG, Principal Dx, Secondary Dx, CPT, E/M, Disposition, and Charge Entry
6. Maintain established productivity benchmarks for Inpatient, Observation, ED, Same Day Surgery, Primary & Specialty Clinic, and Ancillary account types.
7. Maintains a safe environment complying with NLH policies and procedures; reports and directly addresses environmental hazards and violations of patient safety policy and/or protocol when involved or observed.
8. May perform other duties upon request.
RHIT and/or CPC, CIC, COC, CCS, or CCS-P required
ICD-10-CM/PCS and CPT course completion required. Preferred: Associates Degree in HIM. (Uncertified: 12 months to complete certification)
Required Knowledge, Skills and Abilities
1. Demonstrate system values and integrates them into daily organizational practice.
2. Actively support patient-centered care with sensitivity and respect for the diversity of human experience.
3. Ability to work independently and in a team atmosphere.
4. Must be familiar with PCs and work in multiple technical systems simultaneously: Outlook, Cerner EMR, Siemens, 3M 360, and Excel
5. Must be detail oriented
6. Knowledge of ICD-10-CM/PCS, CPT, CMS standards, Official Coding Guidelines, AHA Coding Clinic, and CPT Assistant
7. Strong communication skills with ability to effectively present information and respond to questions
8. Ability to define problems, collect data, establish facts and draw valid conclusions
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.
Work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties.