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Job Summary

The HIM Inpatient Coding Associate is an entry level position that will learn inpatient coding under close supervision by coding leadership. The Associate coder will learn to abstract medical information into the organization billing/abstracting systems and complete the coding function through established best practice processes and professional and regulatory coding guidelines. The Associate coder will take coding concepts learned and apply them to real medical records . The hands on learning opportunity will take place in a setting that conducive to how best coders learn under the direct mentorship of a coding leader, coding educator and/or Sr IP Coding Auditor.

This position will learn and perform Inpatient coding in a supervised setting by assigning International Classification of Diseases (ICD) and International Classification of Diseases-Procedure Coding System (ICD-PCS) codes as well as the Diagnosis Related Groups (DRG) assignment. Abstracts, assigns and verifies codes for Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs), Hospital-Acquired Condition/Patient Safety Indicator (HAC/PSI) and Quality Indicators capture as appropriate through documentation validation. Ensure that each diagnosis present on admission (POA) indicator is assigned appropriately. This position will code for multiple facilities. Adhere to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely and consistent codes.

Data reported by this incumbent is used to meet licensure requirements, is used for statistical purposes, and for financial and billing purposes. Incumbent(s) operate under the supervision of HIM Coding leadership. The associate coder will advance to an HIM Inpatient Coder when all coding levels are complete and an approved certification is obtained if the coder does not already have required certification.

Accountabilities

• Participates in Prisma Health's inpatient Coding Apprentice Program
• Completes of all learning modules and passing of the associated module exams
• Perform entry level by applying ICD and ICD-PCS codes to assigned inpatient records based on review of clinical documentation as per department-specific guidelines and within designated timelines. Follows up on on-hold accounts for final coding. Verifies assignment of DRGs, MCC/CCs, Hospital Acquired Conditions (HACs) and Patient Safety Indicators (PSIs) that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures. Selects the optimal principal diagnoses with appropriate POA indicator assignment and sequencing of risk adjustment diagnoses following established guidelines.
• Perform entry level coding by applying ICD and ICD-PCS codes to inpatient records based on review of clinical documentation
• Learns how to identify and request physician queries following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management (AHIMA) guidelines and established organization policies.
• Actively participates in all training provided online and in person if needed.
• Adheres to department standards for productivity and accuracy.
• Identify And trends coding issues escalating identified concerns to coding leadership.
• Participates in on site, remote and/or external training workshops and training. Attends and participates in CDI-Coding Task Force and other collaborative training and education with CDI, PFS and Quality.
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate coding assignment.
• Performs other duties as assigned.

Management/Supervisory Responsibilities

This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Education

Associate's Degree or Coding Certificate through American Health Information Management (AHIMA) or other approved coding certification program.

Minimum Experience

No previous experience required

Required Certifications

Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC) or other approved coding credential or is eligible to take any of the aforementioned certifications.

Knowledge, Skills, or Abilities

• Knowledge of electronic medical records and 3M or Encoder System.
• Desire to gain hands on experience in professional fee, outpatient facility and inpatient facility coding, in addition to experience working with an electronic medical record (Epic) preferred
• Effective verbal communication skills preferred
• Excellent written communication skills preferred.
• Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
• Knowledge of MS DRG prospective payment system and severity systems.
• Ability to concentrate for extended periods of time.
• Ability to work in a classroom setting as well as independently.

Work Shift

Day (United States of America)

Location

Richland

Facility

1500 Midlands Corporate

Department

15007512 HIM-Coding

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