Inpatient Coding Apprentice

Singing River Health System•Ocean Springs, MS

3d•Onsite

About The Position

The Inpatient Coding Apprentice will evaluate medical records and documentation to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual - Clinical Modification (ICD-10-CM), Healthcare Common Procedure Coding System (HCPCS), Centers for Medicare and Medicaid Services (CMS) documentation requirements and the American Medical Association’s Current Procedural Terminology Manual (CPT). Reviews complex medical records to identify diagnoses, CPT procedures and PCS procedures relative to the patient’s encounter. Selects the principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition. Ensures appropriate DRG assignment. Abstracts appropriate information from the complex medical record. Identifies and reports documentation issues. Solicits clarification from the physician regarding ambiguous or conflicting documentation in the medical record. Ensure all coding complies with the ethical coding standards/guidelines and regulatory requirements. Maintains strictest confidentiality; adheres to all Health Insurance Portability and Accountability Act guidelines/regulations. The Specialist will also provide technical guidance and training on medical coding to physicians and staff.

Requirements

High School diploma or equivalent required.
Must have de-escalation training completed by the end of position orientation (90 days).
Must have appropriate level of de-escalation training.
Proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word.
Must successfully pass the Medical Records Coding tests (CPT and ICD-10) with a score of at least 70%.

Nice To Haves

Experience in medical terminology and anatomy/physiology preferred.
Knowledge of anatomy, physiology and medical terminology.
Knowledge of DRGs/APC’s.

Responsibilities

Evaluate medical records and documentation for completeness, accuracy, and compliance with ICD-10-CM, HCPCS, CMS, and CPT.
Review complex medical records to identify diagnoses and procedures.
Select principal diagnosis and procedure, along with other diagnoses and procedures using UHDDS definition.
Ensure appropriate DRG assignment.
Abstract appropriate information from complex medical records.
Identify and report documentation issues.
Solicit clarification from physicians regarding ambiguous or conflicting documentation.
Ensure all coding complies with ethical coding standards/guidelines and regulatory requirements.
Maintain strict confidentiality and adhere to HIPAA guidelines/regulations.
Provide technical guidance and training on medical coding to physicians and staff.