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
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