The Inpatient Medical Coding Specialist will assign accurate ICD-9-CM and ICD-10-CM codes to inpatient encounters following established coding conventions. They will apply diagnostic and procedural codes to patient health information for data retrieval, analysis, and claims processing. All work will comply with the guidelines of the American Hospital Association (Coding Clinic), CMS, AHIMA, and Memorial Health System. Under the direction of the Coding Manager, the specialist will perform duties according to established standards, policies, and protocols.

Education:

• Associate’s degree in medical record technology or 2-3 years of coding, HIM, or related experience required.  Bachelor’s degree in medical record administration preferred.

Licensure/Certification/Registry:

• Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT)/Registered Health Information Administrator (RHIA) required. Certification must be current.

Experience:

• Requires one year of proven successful inpatient hospital coding experience in abstracting and coding information from patient records using ICD-9-CM.
• Minimum typing skill of 40 WPM and/or 1 year CRT experience required.

Other Knowledge/Skills/Abilities:

• Demonstrates excellent knowledge of proper use of ICD-9-CM and ICD-10-CM coding guidelines and principles, AHA Coding Clinics.
• Accredited training in Medical Terminology and Human Anatomy and Physiology required.
• Knowledgeable of Admission, Utilization Review, Billing and Collection process.
• Demonstrates comprehensive and extensive knowledge of Medicare MS-DRG assignment.
• Demonstrates excellent interpersonal and communication skills.
• Demonstrates ability to work independently, research and solve problems and prepare reports.
• Word processing/computer application experience and knowledge desired.  Coding software familiarity required.

1. Review medical records and accurately code the principal and all secondary diagnoses and procedures using ICD-9-CM and ICD-10-CM coding conventions; sequence the diagnoses and procedures using coding guidelines; abstract and compile data from medical records to assign the most appropriate codes for optimal reimbursement.
2. Coding of Inpatient/Observation Accounts- as assigned performs coding analysis on inpatient/observation accounts utilizing 3M and /or other coding products. Prepares attestation/coding summaries/billing forms as appropriate.  Abstracts all coded records in coding system per procedure.  Assists with post bill audit as directed by Coding Manager.  Ensure the MS-DRG assignment is accurate.
3. Participates in required continuing education and compliance training programs to maintain an understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques to support the effective application of ICD-9-CM and ICD-10- CM coding guidelines to inpatient diagnoses and procedures. Staff will maintain up-to-date knowledge of medical records practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Centers for Medicare and Medicaid (CMS), Federal Intermediary (FI) and other related organizations.
4. Ensures compliance with all current Memorial Medical Center and department policies and procedures.
5. Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the primary/secondary diagnoses and procedures using ICD-9-CM and ICD-10-CM coding conventions. Assist with research and development, and presentation of continuing education programs on areas of specialization.
6. Productivity (quantity & quality) is a higher level than for Healthcare Coding Associate and Healthcare Coding Specialist.
7. Communicates with patient services to resolve billing/coding matters. Demonstrates ability to cooperate with Memorial Medical Center management personnel, physicians and other persons contacted during the working day.  Works directly with physician and Allied Medical Staff to clarify coding issues.  Utilizes physician documentation query form effectively.
8. Enter and retrieve patient medical data from computer terminal updating entries as necessary; audit medical record for accuracy and completeness, note deficiencies and refer for appropriate follow up and completion.
9. Assist with the training of employees in the use of coding manuals; review difficult classification situations and determine the most appropriate codes; monitor work of subordinate employees to ensure accuracy and completeness of assignments.
10. Participates in monthly coding meetings with Coding supervisors, CDI team, and others, as determined.
11. Serve as a member of designated divisional committees and other steering committees as appropriate.
12. Promotes MHS Guest Relations philosophy, Statement of Values, and follows MHS Behavior Standards and Code of Conduct.
13. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.