A Brief OverviewRequires review of medical record documentation to accurately assign International Classification of Diseases (ICD-10-CM/PCS), as well as assignment of the Medicare Severity Diagnosis Related Group (MS-DRG) / All Patient Refined - Diagnosis Related Group (APR-DRG) and abstracts specific data elements for each account in compliance with federal and state regulations. This position codes the majority of patient types of inpatient records, including more complex cases such as Intensive Care. Follows the Official Guidelines for Coding and Reporting, the American Health Information Management Association (AHIMA) Standards of Ethical Coding, as well as all American Hospital Association (AHA) Coding Clinic guidance. Follows Stanford Health Care policies and procedures and maintains required quality and productivity standards. Reviews, abstracts and assigns accurate and ethical ICD-10-CM/PCS codes to inpatient services. Ensures compliance with third party, State and Federal regulations. Reviews, analyzes and abstracts physician/other documentation for diagnoses, procedures, and other services provided. Obtains missing information and/or clarifies existing information. Completes volume of work from work queues per departmental productivity standards. Groups codes and completed product into payment group. Analyzes information for optimal and approprite reimbursement. Ensures compliance with all appropriate coding, billing and data collection regulations and procedures. Uses appropriate software to validate information. Utilizes Epic, 3M Coding and Reimbursement System (Encoder), 3M CDIS, 3M Audit Expert, MS Office, and other software as appropriate to compile and validate medical information.
LocationsStanford Health Care
What you will do- Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnosis and procedure codes, leading to the assignment of the correct Medicare Severity-Diagnosis Related Group (MS-DRG) or All Patient Refined Diagnosis Related Group (APR-DRG). The Inpatient Coding Specialist II is responsible for verification of the patient's discharge disposition, assignment of the correct sources of admission for state regulation reporting purposes, and ensuring the appropriate present on admission (POA) indicators are assigned to each code. The assigned codes must support the reason for the visit that is documented by the provider in order to support the care provided.
- Correctly abstracts required data per facility specifications.
- Responsible for monitoring Discharged Not Billed accounts, and as a team, ensuring timely, compliant processing of inpatient accounts through the revenue cycle.
- Collaborates with Clinical Documentation Specialists (CDSs) and members of the medical staff to ensure completeness of documentation in the medical records so that appropriate codes, and, ultimately, the correct Diagnosis Related Group (DRG) may be assigned.
- Responsible for ensuring accuracy and maintaining established quality and productivity standards.
- Demonstrates a high degree of independence in performance of responsibilities, working effectively without direct supervision. Exhibits strong time management, problem solving and communication skills.
- Possesses critical thinking, good judgment and decision making skills.
- Demonstrates excellent written and oral communication skills.
- Remains abreast of current Centers for Medicare and Medicaid Services (CMS) requirements as well as Correct Coding Initiative (CCI) edits, Hospital Acquired Conditions (HACs), Patient Safety Indicators (PSIs), and when applicable, National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs,) including the addition of appropriate modifiers to ensure a clean claim the first time through.
- Maintains competency and accuracy while utilizing tools of the trade such as the 3M encoder, 3M Audit Expert process (3M AES), 3M Clinical Documentation Improvement System (3M CDIS) and abstracting systems, as well as all reference materials.
- Follows all established Stanford Health Care policies and procedures.
- Attends required system, hospital and departmental meetings and educational sessions as established by leadership, as well as completion of required annual learning programs, to ensure continued education and growth.
Education Qualifications- High School Diploma or GED equivalent
Experience Qualifications- Five (5) years of progressively responsible and directly related work experience
Required Knowledge, Skills and Abilities- Successful completion of the Coder Proficiency Exam (pre-hire)
- Ability to adapt to and deal with change and ambiguity
- Ability to plan, organize, prioritize, work independently and meet deadlines
- Ability to comply with the American Health Information Management Association's Code of Ethics and Standards and apply Uniform Hospital Discharge Data Set (UHDDS) standards
- Ability to establish and maintain effective working relationships
- Ability to manage, organize, prioritize, multi-task and adapt to changing priorities
- Ability to solve technical and non-technical problems
- Ability to utilize the ICD-10-CM/PCS and CPT-4 coding conventions to code medical record entries; abstract information from medical records; read medical record documentation; assign accurate codes for grouping of MS-DRGs and APR-DRGs
- Ability to work effectively through and with others
- Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
- Knowledge of health information systems for computer application to medical records
- Ability to foster effective working relationships and build consensus
- Ability to work effectively with individuals at all levels of the organization
- Knowledge of CCI (Correct Coding Initiatives) and CMS compliance issues
- Knowledge of computer systems and software used in functional area
- Knowledge of standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; medical terminology; anatomy and physiology and study of diseases
Licenses and Certifications- RHIA - Registered Health Information Administrator or
- RHIT - Registered Health Information Technician or
- CCS - Certified Coding Specialist
Base Pay Scale: Generally starting at $66.10 - $74.44 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.
