RN CODER

Job Summary:

Performs final, ICD-10-CM diagnosis coding and ICD-10-PCS on Inpatient Encounters. Responsible for capturing MCC, CC and all secondary diagnosis with assignment of the correct DRG based on documentation. RN Inpatient coders help insure the data integrity of the patient’s clinical record. RN Inpatient coders must be able to assign present on admission indicators appropriately. RN Inpatient coders are responsible for the abstraction of ADT information at the time of final coding. RN Inpatient Coders must be able to effectively communicate with the medical staff, other departments, and teammates through queries, email, telephone, teleconference and/or face to face encounters. RN Inpatient Certified Coders are responsible for maintaining continuing education hours necessary for current certifications. Coders are expected to research diagnosis and procedure techniques to ensure assignment of the appropriate ICD10 CM and ICD10 PCS codes. Uses EPIC and 3M software to review the electronic medical record and the 3M encoder to code and calculate the billing DRG and assign POA indicators. RN Inpatient coders are to understand the impact coding makes on quality reporting and have working knowledge of CMS quality programs. RN Inpatient coders are expected to work cooperatively with other team members. Performs clerical duties as required or as designated by the Director, Manager or Supervisor

Performs final ICD-10-CM, ICD-10 PCS diagnosis coding on Inpatient Ambulatory Surgery, Observation, Emergency Service and Outpatient records (includes lab, radiology, radiation oncology, peripheral vascular radiology, endoscopy, cardiac cath. lab, and any other outpatient record requiring diagnosis coding). Applies ICD-10-CM, ICD-10 PCS and CPT-4 codes to procedures performed in emergency services, cardiac cath lab, endoscopy, ambulatory surgery, observations, OB checks, outpatient blood transfusions, peripheral vascular radiology, and outpatient chemotherapy. Provides ICD-10-CM, ICD-10 PCS and CPT codes to Business Services for cycle billing of series outpatients. Interacts with physicians or physician’s offices staff as necessary to obtain clinical information needed to accurately assign ICD-10-CM or CPT-4 codes. Uses the EPICS software to review the electronic medical record and to enter diagnosis and procedure codes for billing based on the documentation. Serves as a resource to Business Services, HIM, and other departments with questions related to emergency or outpatient coding and the applicable ICD-10-CM and CPT-4 coding guidelines. Responsible for ensuring proper APC/DRG assignments as appropriate. Works cooperatively with other team members. Performs clerical duties as required or as designated by the Director, Manager or Supervisor. Demonstrates knowledge and skills to appropriately communicate and interact with the patients, families, and visitors of all age groups while being sensitive to their cultural and religious beliefs.

Performance Expectations:

Demonstrates ability to code records according to set productivity standards. Demonstrates the ability to work edits received from patient accounts. Demonstrates the ability to abstract (i.e., correct codes, dates, surgeon information, and discharge status) all records within 4 days of patient discharge to ensure timely reimbursement. Demonstrates the ability to maintain performance standards set by the department.

Qualifications:

Education/Skills

Associates Degree in Nursing, Bachelor of Science Degree in Nursing. In the process of obtaining (within the next 24 months) Completion of formal certification in ICD-10, CPT Coding, Medical Terminology, Anatomy/Physiology and Disease Processes.

Work Experience:

Minimum of 3 years acute care nursing experience with preferred experience in coding both Inpatient and/or Outpatient records.

Certification/Licensure-DUE UPON HIRE

• Licensed RN able to practice within the State of MS

Additional Certification/Licensure - Obtained based on required timeframe below

• CCS, COC, CIC RHIA or RHIT Certification

Within 1 Year of Employment

Preferred

Mental Demands:

Exceptional oral and written skills are required to relate effectively to hospital staff, physicians, and review Agencies. The individual must have the ability to type and be familiar with the rules of spelling, grammar, and punctuation. The individual must have the ability to use a copier, telephone, personal computer, and fax machine. Knowledge of DNV Standards and other regulatory systems is essential. Working knowledge of official coding guidelines and prospective payment systems and reimbursement guidelines are necessary. The individual must have a high energy level and be capable of handling pressure situations both mentally and physically.