Requires superior knowledge of and skill in applying International Classification of Diseases and Procedures (ICD), and Current Procedural Terminology (CPT) code sets and associated Medicare/Medicaid rules and guidelines. Reviews and interprets patient medical record documentation to identify pertinent diagnoses and procedures and assigns ICD-10-CM, ICD-10-CM/PCS and CPT 4 codes accurately and timely to the highest level of specificity based upon physician documentation for inpatient, observation and outpatient ambulatory procedures/treatment room records. Validates the coded data to one or more Diagnosis Related Groupers (DRG) validates the Present on Admission (POA) indicators for accuracy and identifies and reports hospital acquired conditions (HACs). Primarily codes more complex and difficult inpatient medical records. Identifies and abstracts specified information from the patient medical record and enters data into the medical record abstract data base system for billing and use in all types of CCHCS reporting. Performs extended length of stay coding for interim cycle billing. May perform and facilitate concurrent inpatient coding in order to establish a working DRG and reviews for documentation opportunities and queries with CDIS to clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time. Assists with coding outpatient surgery, observation outpatient ancillary clinic, specialty clinic and emergency room record visits as necessary. Minimum expected accuracy rate for all coding & DRG assignments is 95% or above. Communicates with physicians and other providers regarding documentation requirements and collaborates with Clinical Documentation Specialists on patient cases regarding documentation needs and requirements, and coding and DRG assignment accuracy. Maintains current knowledge of coding, DRG and documentation changes, rules and guidelines.
High school or equivalent required
RHIA, RHIT or CCS with two (2) year minimum current full-time current and continuous ICD-10-CM hospital inpatient medical record prospective payment, observation and outpatient surgery coding experience with DRG assignment and CPT-4 outpatient coding and abstracting experience required.
Pediatric coding experience highly desired.
Technically competent and fluent knowledge in navigation of electronic medical record applications, automated encoders, and other software applications and hardware required for job role required. Experience using Microsoft Office Excel and Word highly desired.
Ability to work well independently and productively with minimal guidance and without direct supervision. Must be highly detail oriented, have the ability to remain focused with good organization, interpersonal and communication skills.
Ability to maintain confidentiality.
Goal oriented, flexible and energetic.
Demonstrates superior coding skills, and critical thinking skills.
Ability to solve problems appropriately using job knowledge and current policies and procedures.
Demonstrated coding knowledge and proficiency is required through on-site evaluation prior to hire.
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) required. Required to provide current American Health Information Management Association (AHIMA) continuing education certification records.
*Position is remote-friendly within the state Texas*
Internal Number: 38671
About Cook Children's Health Care System
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.