Medical Coder III (Inpatient Coder)

Job Summary:

Required Services provide single path medical coding services and related medical records functions. Single path coding combines facility coding and professional coding and allows one coder to code facility and professional codes for the same patient utilizing a single coding platform. perform technically complex professional services coding for medical conditions and assign the correct International Classification of Diseases, ICD-10-CM, Procedure Coding System (PCS) Current Procedural Terminology (CPT), Health Care Financing Administration Common Procedure Coding System (HCPCS), and Evaluation and Management (E&M) codes for diagnosis, acuity of care and procedures for a wide range of medical specialties to include coding of complicated cases identified as difficult to classify such as treatment of burn injuries, combat related injuries, orthopedic surgery, cardiothoracic surgery, interventional radiology, new diseases, new and experimental treatments or therapies and infections, etc.

Duties:

• Accurately assigns Evaluation and Management (E&M) codes, International Classification of Diseases, Clinical Modification (ICD-CM) diagnoses, ICD-10 Procedure Coding System (ICD-10-PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), modifiers, and quantities derived from medical record documentation (paper or electronic) for the professional and institutional (facility) components of inpatient facility discharges (stays); inpatient professional services to include attending (also known as "Rounds"), consultations, and concurrent services, and inpatient surgical and anesthesia procedures; and inpatient External Resource Sharing Agreement (ERSA) encounters. May also code ambulatory (i.e. Coder II) or outpatient (i.e. Coder I) encounters as directed.

• Reviews encounter and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that may cause inaccurate coding, medico-legal repercussions or impacts quality patient care.

• Educates and provides feedback to providers and clinical staff to resolve documentation issues to support coding compliance.

• Assigns accurate codes to encounters based upon provider responses to coding queries.

• Acts as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Collaborates with and supports medical coding auditors, trainers, and compliance specialists in providing education and feedback to providers and staff.

• Supports DHA coding compliance by performing due diligence in ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channels.

• Upon DHA-MCPB direction, utilizes MHS computer systems to remotely access patient records and assign codes for patient encounters in support of other MTFs.

• Achieve and maintain DHA coding productivity and accuracy standards for the position.

Qualifications:

• Education: Post-high school education through a university or technical school program resulting in completion of ONE of the following: 1) An Associate's degree or higher in Health Information Management, Healthcare Administration, or a biological science; OR 2) A university certificate in medical coding; OR 3) At least 30 semester hours' university/college credit that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology; OR 4) Successful completion of an American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) coding certification preparation course for professional services or facility coding that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology; OR 5) Successful completion of a training course beyond apprentice level for medical technicians, hospital corpsmen, medical service specialists, or hospital training, obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision. General medical ethics, telephone etiquette, and excellent communication and customer service skills.

• Certification: ONE of the following recognized professional coding certifications: Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist - Physician (CCS-P); AND ONE of the following recognized institutional coding certifications: Certified Inpatient Coder (CIC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS); AND ONE of the following recognized E&M coding certifications: Certified Evaluation and Management Coder (CEMC), or National Alliance of Medical Auditing Specialists' (NAMAS) Certified Evaluation and Management Auditor (CEMA).