Inpatient Coder - HIM Specialist

Mary Free Bed Rehabilitation Hospital•Grand Rapids, MI

About The Position

Review clinical documentation and diagnostic results to extract data and apply appropriate ICD-10-CM codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the Manager of Health Information Management, accurately code inpatient conditions and procedures according to the ICD-10-CM Official Guidelines for Coding and Reporting. Assist with workflow changes to reduce billing errors and stay current with applicable federal, state, regulatory, and hospital-specific coding guidelines. The role assigns etiology and comorbidity codes for inpatient admissions in accordance with IRF PPS guidelines; reviews provider documentation at discharge to identify diagnoses, complications, secondary conditions, and procedures; and applies coding principles and CMG reimbursement expertise to code diagnoses and procedures for the UB-04 and IRF-PAI. The coder analyzes records for completeness and code justification, researches and follows up on unresolved issues, and queries providers when documentation is conflicting, incomplete, or ambiguous. The position also supports physician education, monitors IRF-PPS policy changes, and follows AHIMA ethical coding standards and official coding guidelines. The role promotes customer service, teamwork, direct communication, discretion with confidential information, and participation in quality-improvement efforts. The listed physical requirements include remaining stationary for the majority of the time, frequent keyboard use and communication, and occasional handling of loads up to 10 pounds.

Requirements

Associate degree or equivalent training through at least five years of progressive on-the-job experience.
RHIA, RHIT, or CCS certification.
Advanced understanding of anatomy and physiology, medical terminology, and record-documentation requirements.
Familiarity with HIM principles and practices and their application to hospital records and coding.
Strong oral and written interpersonal skills.
Time-management skills to handle competing demands and priorities and work effectively under pressure.
Intermediate knowledge of Microsoft Office, including Word, Excel, and PowerPoint.
Ability to learn quickly and ask discerning questions.
Sense of urgency and ability to adapt quickly to changing priorities.
Collaborative team style and open communication, including across departments and sites.
Self-directed, organized, and able to reason objectively.
Ability to work independently and in a group in a multitasking environment.
Excellent analytical and problem-solving skills.
Demonstrated commitment to the organizational mission and a “whatever it takes” attitude.
Credible and trustworthy.
Information-management skills and ability to interpret, communicate, and present data.

Nice To Haves

IRF coding experience and/or acute-care hospital inpatient coding experience.

Responsibilities

Assign etiology and comorbidity codes for inpatient admissions in accordance with IRF PPS coding guidelines, collaborating with the UR Coordinator, PPS Specialist, and/or attending physician as needed.
Review and research provider documentation after inpatient discharge to determine principal diagnoses, comorbid conditions, complications, secondary conditions, and surgical procedures.
Apply coding principles and CMG reimbursement expertise to assign ICD-10-CM codes to diagnoses and procedures, and record codes for the UB-04 and IRF-PAI in accordance with IRF PPS requirements.
Analyze records for completeness and appropriate code justification; conduct additional research and follow-up when needed.
Query physicians or other qualified healthcare practitioners for clarification or additional documentation when health-record information is conflicting, incomplete, or ambiguous.
Maintain awareness of IRF-PPS policy changes, tier codes, documentation requirements, and coding guidelines.
Provide physicians with education about documentation requirements for accurate code assignment.
Follow AHIMA Standards of Ethical Coding and official coding guidelines.
Demonstrate excellent customer service and behavioral standards; encourage, coach, and monitor those standards in team members.
Promote teamwork and direct communication, and handle confidential information discreetly and sensitively.
Identify problems and seek solutions; support patient and family satisfaction and participate in departmental customer-service monitoring and reporting.