MEDICAL CODER

General Purpose of Job:

Advanced coding position that requires review of medical record documentation and accurately assigns ICD-10-CM, ICD-10 PCS, as well as assignment of the Medicare Severity Diagnosis Related Group, (MS-DRG) / All Patient Refined - Diagnosis Related Group, (APR-DRG) based on payor classification and abstracts specific data elements for each case in compliance with federal regulations. This position codes all types of inpatient records and follows the Official Guidelines of Coding and Reporting, the American Health Information Management Association, (AHIMA) Coding Ethics, as well as all American Hospital Association, (AHA) Coding Clinics, CMS directives and bulletins, Fiscal intermediary communications. Utilizes Optum CAC in accordance with established workflow. Follows University of Michigan Medicine - Sparrow policies and procedures and maintains required quality and productivity standards.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Extracts, reviews, and analyzes clinical information, identifies and abstracts all pertinent information and translates data into appropriate codes for hospital billing, POA and PSI indicators, research, statistics, financial planning, compliance and marketing to ensure completeness, accuracy and compliance with established guidelines of all governmental regulatory agencies and third-party payers.
• Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnoses and procedure codes, leading to the assignment of the correct Medicare Severity-Diagnosis Related Group, (MS-DRG) or All Patient Refined Diagnosis Related Group, (APR-DRG.)
• The Inpatient Coding Specialist is responsible for verification of the patient's discharge disposition and to ensure the appropriate present on admission (POA) indicators are assigned to each code. The assigned codes must support the reason for the visit that is documented by the provider to support the care provided.
• Correctly abstracts required data per facility specifications.
• Exercises independent judgment in determining case complexity by utilizing clinical knowledge to understand the etiology, pathology, signs, symptoms, diagnostic studies, treatment modalities and prognosis of diseases and procedures to be coded. Researches complex diagnoses and/or procedures as needed to enhance coding knowledge to consistently apply the correct ICD-10-CM and ICD-10-PCS codes.
• Captures the correct principal diagnosis, co-existing conditions, and principal procedure for each inpatient admission. Works in collaboration with CDI team to consult with the providers to clarify or improve documentation for correct coding assignment to ensure correct data reporting and reimbursement and to maintain compliance with Federal and State regulations.
• Responsible for sequencing codes that capture accurate Severity of Illness/Risk of Mortality.
• Interacts closely with the Clinical Documentation Specialists and DRG Compliance Auditors to query the medical staff appropriately and professionally to obtain accurate documentation necessary to ensure coding compliance and accuracy.
• Expands job-related knowledge and skills by attending and participating in in-services and staff meetings. Keeps abreast of coding guidelines and quarterly AHA Coding Clinic.
• Attends required system, hospital and departmental meetings and educational sessions as established by leadership, and completes required annual learning programs, to ensure continued education and growth.
• Responsible for ensuring accuracy and maintaining established quality and productivity standards, as well as key performance indicators.