Clinical Coding Specialist
Codes complex inpatient records to include Trauma Level I, transplant, and multiple complex surgical procedures. Reviews clinical documentation and diagnostic results as appropriate to extract data and apply ICD-10-CM/ICD-10-PCS and CPT-4 codes for hospital reimbursement, mortality & morbidity outcomes, governmental compliance, research & statistical, internal and external reporting, research, and regulatory compliance.
Accurately codes complex inpatient encounter diagnoses, procedures and/or modifiers supported by health information record documentation per ICD-10-CM/ICD-10-PCS official coding guidelines for coding and reporting.
Abstracts, codes and assigns necessary demographic and clinical data elements required for inpatient records. Reviews charge capture of complex cardiac procedures for accuracy. As necessary, consults or queries the physician for additional information or clarification of diagnoses, co-morbid/secondary conditions, and procedures.
Performs other related duties as requested by HIM management.
- Minimum of 3 years of coding experience in a hospital setting required.
- Associate degree preferred.
- Certified Coding Specialists (CCS) or Certified Inpatient Code (CIC) required. Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred.
- High School Diploma or equivalent
- Associate Level Degree preferred
- Certified Coding Specialists (CCS) or Certified Inpatient Code (CIC) required.
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician
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