IP​/OP Coder

Job Overview

The Hospital Inpatient Coding Specialist reviews inpatient medical records and assigns International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10 CM) diagnosis and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) procedure codes that derives an All Patient Refined Diagnosis Related Group (APR-DRG) or Medical Severity Diagnosis Related Group (MS-DRG) for optimal reimbursement. The Hospital Inpatient Coding Specialist will work in collaboration with the Clinical Documentation Integrity Specialist at times to ensure accuracy consistent with Centra’s coding policies.

The Hospital Inpatient Coding Specialist will abstract pertinent information according to established guidelines for the organization and will formulate provider queries to clarify information.

• Assign diagnosis and procedure codes.
• Verify accuracy of DRG.
• Accurately abstract required information.
• Initiate provider coding queries in compliance with coding guidelines and policies where appropriate.
• Meet productivity standard of 2 charts per hour or higher.
• Meet coding accuracy of 95% or higher.
• Verify and assign discharge status codes.
• Ensure presence of a completed Medicaid certification prior to finalizing coding.
• Appropriately assign the Hospital Acquired condition (HAC) and Present on Admission (POA) indicator for each diagnosis.
• Communicate with Clinical Documentation Integrity (CDI) Specialist via email, phone, or other methods regarding accounts.
• Participate in team, organization and educational meetings.
• Maintain and continually enhance coding competency, through participation in educational programs, reading official coding publications such as the American Hospital Association’s (AHA) Coding Clinic for ICD-10-CM/PCS, AHA Coding Clinic for HCPCS, AMA CPT Assistant to stay abreast of changes in codes, coding guidelines, regulatory and other requirements.
• Maintain coding credential(s) by completing continuing education requirements of credits per year.
• Assist in achieving department goals of Accounts Receivable days in regard to Discharged Not Final Billed (DNFB).

• High School Diploma or equivalent, bachelor's degree preferred.
• One or more of the following certifications required: RHIA, RHIT, CCS or CCA.
• Minimum of 2 years acute care inpatient coding experience required.
• Experience in coding across multiple specialties within a hospital coding environment and remote coding experience preferred.
• Demonstrated proficiency in ICD-10-CM and ICD-10-PCS by passing coding competency assessment administered before hire.
• Demonstrated proficiency in medical terminology, anatomy and physiology, and disease process by passing coding competency assessment administered before hire.
• Good working knowledge of Inpatient Prospective Payment System (RPPS), Diagnosis Related Group (DRG) methodologies, Severity of Illness (SOI), and Risk of Mortality (ROM).