Job Summary: For the purposes of complete accurate clinical documentation, reimbursement, reporting and research, follows established MHS Guidelines, policies and procedures, in accordance with all Federal & State coding rules, regulations and reporting requirements. Codes all payer types inpatient records including Government Medicare Medical Serverity-Diagnosis Related Group (MS-DRG) and Medicare Inpatient Rehab (CMG) and APR-DRG for Medi-Cal payer types as needed according to diagnoses, operations and procedures using appropriate classification systems. Abstracts designated demographic and clinical data for profiling and benchmarking. Ensures correct code assignment, modifier use and sequencing to provide for maximum achievable accuracy & completeness of clinical documentation and allowable hospital reimbursement under the Federal Government's Perspective Payment System for acute inpatient hospitals, as well as ensuring appropriate SOI (Severity of Illness) and ROM (Risk of Mortality) scoring for benchmarking and quality reporting to CMS (Centers for Medicare and Medicaid Services), TJC (The Joint Commission), OSHPD (Office of Statewide Health Planning and Development), and other benchmarking agencies.
Duties & Responsibilities: * Reviews Inpatient medical record of all payer types including Medicare, Medi-Cal, MS-DRG & APR-DRG payer types to determine the principal diagnosis and procedure, and to identify all co-morbid conditions or complications, or secondary procedures that impact reimbursement and/or severity and risk of mortality; consults with physician when documentation clarification is necessary * Following all regulatory guidelines optimizes MS-DRG/APR-DRG reimbursement for each chart coded, using experience and initiative in sequencing diagnosis and procedure codes * Following state and federal guidelines, determines those conditions not present on admission and flags accordingly for POA (Present on Admission) * Using the International Classification of Diseases (ICD9/10 CM/PCS) coding classification systems assigns codes to all diagnoses and procedures following applicable coding principals and department guidelines; enters into the computer coding system * Using the 3M APR DRG Classification System provides SOI and ROM scores for use by commissions and state agencies to disseminate comparative performance data to regulators, payers, and the general public * Abstracts and codes all required clinical and demographic data for reporting to CMS (Centers for Medicare and Medicaid Services), OSHPD (Office of Statewide Health Planning and Development), Quality Management, and Medical Staff; enters information into the computer abstracting system * Codes CMG payer type accounts into the Uniform Data System (UDS) for government reimbursement and reporting, following federal guidelines for coding acute rehab encounters; consults with physician when documentation clarification is necessary * Maintains current knowledge of the most recent ICD-9-CM/ICD-10 CM/PCS Official Guidelines for Coding and Reporting, the annual changes to the ICD9/10 diagnosis and procedure codes, the annual changes to the inpatient perspective payment system, as well as the annual changes to the CMG reporting and reimbursement system * Demonstrates the ability to accurately and timely code all medical records, including Medicare, Medi-cal, to expedite hospital reimbursement, clinical pertinence and indices * Demonstrates the ability to accurately & timely code all medical records, including all payer types and all patient classifications to expedite hospital reimbursement, clinical pertinence and indices * Assist other coders, PFS, Registration staff & billers by providing information to expedite billing. Demonstrates the ability to take job ownership by offering suggestions and showing a commitment to job completion * Communicates effectively with supervisor, peers and others requiring interactions * Achieves optimal MS-DRG and APR-DRG reimbursement * Ensures appropriate SOI/ROM scoring * Meets facility standards for correct diagnoses and procedure code assignment (ie. accuracy goals) * Meets facility standards for QM data/physician assignment/OSHPD required data * Meets WAR report productivity goals 97% of the time * MUST BE WORKING ON-SITE AT SADDLEBACK MEMORIAL MEDICAL CENTER FIRST 90 DAYS OF EMPLOYMENT FOR TRAINING. AFTER WILL WORK REMOTELY.
REQUIRED SKILLS: Experience & Qualifications: * 5 years ICD-9 coding and DRG reimbursement experience in an acute care hospital * Expert knowledge of MS-DRG methodology * Experience with 3M APR-DRG software (preferred) * Expert knowledge of Severity of Illness and Risk of Mortality methodology * Expert knowledge of ICD-9, ICD-10 CM & PCS coding
Education: * High school diploma or GED equivalent required * At least one CCS, RHIT or RHIA required