Responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based on documentation in the electronic medical record while maintaining compliance with established rules and regulatory guidelines.
Key responsibilities include:
- Accurately assign ICD-10-CM and ICD-10-PCS codes using an electronic encoder application.
- Review medical record documentation and abstract data into the encoder and EHR.
- Determine principal/final diagnosis, co-morbid conditions, complications, secondary conditions, and procedures.
- Initiate physician queries when diagnoses or procedures need clarification.
- Maintain coding quality, productivity, and established coding timeframes.
- Support accounts receivable goals related to uncoded accounts.
- Participate in coding meetings, education, and continuous improvement efforts.
Requirements & Qualifications
Education
- Associate’s degree or higher in a CAHIIM-accredited program, or two additional years of experience in lieu of degree.
Experience
- One year of relevant inpatient coding experience, or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program.
Certifications
- RHIT (AHIMA)
- RHIA (AHIMA)
- CCS (AHIMA)
Skills and knowledge
- Knowledge of coding classification systems, DRG and APC systems, official coding guidelines, and coding compliance.
- Working knowledge of medical terminology, anatomy, and physiology.
- Experience with electronic medical records and imaging systems preferred.
- Proficiency with electronic encoder applications preferred.
- Strong PC skills and ability to use office software, coding software, and abstracting systems.
- Strong communication skills and ability to work with patients, physicians, family members, and co-workers.
Location
Texas, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 weeks ago
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