Inpatient Coder

Company: Kaiser
Location: Union City
Posted on: January 18, 2023

Job Description:

Job Summary:Under direct supervision, the Inpatient Coder is responsible for the accurate coding and abstracting of inpatient cases or services (diagnosis, conditions and procedures) from medical record documentation. -Assign codes and modifiers using the appropriate version of ICD-CM, ICD-PCS, CPT and HCPCS as well as other specialty systems as required by diagnostic category. -The Inpatient Coder is expected to code and abstract Observation (OBS), Hospital Ambulatory Surgery (HAS), Emergency Department (ED), and complex Hospital Outpatient Visit (CHOY) services when needed. - - -All work must be performed in accordance with the rules, regulations and coding conventions of ICD-CM Official Guidelines for Coding and Reporting, Coding Clinic published by the American Hospital Association, the ICD-CM, ICD-PCS, CPT and HCPCS code book, CPT Assistant, NCCI Edits, CMS, OSHPD and Kaiser Permanentes organizational and institutional coding guidelines.Essential Responsibilities:

• Coding and Abstracting: Reviews medical record documentation to identify diagnoses/procedures to be coded.
• Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
• Codes all appropriate diagnosis and procedures from the medical record using ICD-CM, ICD-PCS, CPT and HCSPCS coding classification systems.
• Responsible for the sequencing of diagnoses and procedures in accordance with guidelines outlined in ICD-CM, ICD-PCS, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems.
• Determines that the DRG is appropriate for each case and reviews DRG discrepancies to ensure appropriate group of each case.
• Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting.
• Corrects data when needed.
• Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS and regional and local KP policies.
• Ensures the accuracy and integrity of data abstracted and coded based upon medical record documentation prior to data submission or coding completion.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
• Ensures timely data completion by meeting coding/abstracting productivity/quality -standards established for the Inpatient Coder position.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
• Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
• Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.
• Demonstrates knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
• Other Duties: Performs other duties as assigned.Grade 650Basic Qualifications:Experience
• Three years of continuous hospital coding experience within the last five years.Education
• High School Diploma or GED and demonstrated completion of classes in medical terminology, anatomy, physiology, current ICD-CM, ICD-PCS and CPT coding conventions and disease process from an accredited program.License, Certification, Registration
• Registered Health Information Technician Certificate OR Registered Health Information Administrator Certificate OR Certified Coding Specialist -Additional Requirements:
• Basic knowledge of and use of computer keyboard and mouse.
• Achieve a minimum score of 75% on the KP Inpatient Coding test.
• Must be able to meet productivity and quality standards established for the position.
• Demonstrated ability to understand the clinical content of a health record and translate to coding.
• Demonstrated knowledge of anatomy, physiology, medical terminology and disease process to interpret general medical classifications for inpatient services.
• Demonstrated knowledge regarding the review of cases for coding quality and coding compliance.
• Basic knowledge of reimbursement methodologies and conventions and knowledge of rules and guidelines for the appropriate and current coding classifications.
• Ability to communicate with physicians regarding the clarification of dagnoses/procedures and the sequencing of diagnoses.
• Must maintain coding credential and complete the required Continuing Education (CE) units.
• Must abide by the AHIMA and AAPC code of ethics.
• Must be willing to work in a Labor Management Partnership environment. -Preferred Qualifications:
• N/AJob Schedule: Job Category: Health Information Management

Keywords: Kaiser, Union City , Inpatient Coder, Other , Union City, California