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Medical Coder (Inpatient Coding)

3+ years Inpatient Facility Coding

Fulltime (remote)

1 Opening

Kochi, India

- Inpatient Coder is responsible for reviewing documentation in the electronic medical record and assigning and sequencing ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, following the Standards of Ethical Coding as set forth by AHIMA and AAPC and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. - Inpatient Coder must be proficient with the various Diagnosis Related Groups (DRG) methodologies, including Medicare Severity DRGs (MS-DRGs) and All Patient Refined DRGs (APR-DRGs). - The Inpatient coder codes all case types: including, transplant, major trauma, and mortality records, as well as any accounts identified for interim billing or tentative DRGs. The Inpatient coder participates in the compliant physician query process and will collaborate with the hospital team regarding clinical validation queries and the DRG reconciliation process as applicable. The Inpatient coder will partner with the Inpatient Coding Quality Analysts and the Inpatient Coding Supervisor for education and quality monitoring. The Inpatient coder will assist with any quality metric questions that may arise. This individual may assist with responding to external coding reviews from private payers as well as government contractors. The Inpatient coder will interact with physicians and other clinicians with minimal supervision as it pertains to coding and documentation.

Job description

– Review, analyze, and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.

– Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology, and pathophysiology/disease processes.

– Identify cases with clinical indicators that may require provider documentation clarification and/or specificity to accurately assign codes.

– Analyze code assignment and sequence to ensure proper MS DRG assignment; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS), and other regulatory requirements to accurately assign the DRG.

– Analyze medical record documentation for optimum severity of illness and risk of mortality scores

– Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary

– Suggest and assist with workflow process improvements as appropriate. Participate in coding quality and productivity processes.

– Identify topics of high priority for training and clarification and refer them to the Supervisor/Manager

– Keep abreast of annual and periodic updates to the ICD-10 coding system and regulations to provide expert coding advice to colleagues.


Licenses & Certifications:

– Certified Inpatient Coder (CIC) required.


Preferred Skills:

– Knowledge of, but not limited to, current Official Coding Guidelines and methodologies, MS-DRGs, APR-DRGs, and the ICD-10-CM/PCS coding systems and conventions.

– Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology, and ancillary test results

– In-depth knowledge of complex medical and coding concepts encountered in an Academic Medical Center.

– Knowledge of coding systems and regulatory requirements of the Inpatient Prospective Payment System (IPPS)

– Proficiency with encoder software and other coding applications/tools

– Strong communication skills (interpersonal, verbal, and written).

– Strong organizational and analytical thinking skills

– Demonstrates critical thinking skills, and ability to interpret, assess, and evaluate provider documentation.

– Self-motivated and demonstrated capacity to work independently without close supervision.

– Ability to quickly analyze a situation, problem solve, and prioritize.

– Familiarity with the external reporting aspects of healthcare

– Knowledge of external auditing programs; ex.: Recovery Audit Contractor (RAC), Office of the Inspector General (OIG), third-party payors