Inpatient Coding Specialist Case Study
Martins Children’s Hospital
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Job Detail Inpatient Coding Specialist-MCH HIMS position
Job Title Inpatient Coding Specialist - MCH HIMS
Job # 12398
Department Name HIMS Coding
Hospital MCH
Job Type Full Time
Schedule Monday - Friday
Job Description
The Coding Specialist is responsible for coding and abstracting inpatient records utilizing ICD-9 diagnosis and procedure codes, in accordance with coding conventions and
guidelines. This requires thorough review of the medical record to validate assigned codes, assure optimum reimbursement and accurate abstraction of required data. Must be able to recognize when further documentation is necessary for accurate code assignment and appropriately query the physician (or others) for clarification, onsite or Remote work available within the state of Texas only. Essential Functions
1. Demonstrates a high degree of independence in performance of responsibilities, working effectively without direct supervision.
2. Demonstrates competency in coding and abstracting all patient types in accordance with ICD-9 and
CPT coding conventions and national coding guidelines, meeting the expected monthly quality and productivity standards according to departmental policy.
3. Maintains an understanding of regulations, standards and practices as they relate to Health
Information Management.
4. Participates in continuing education opportunities and shows initiative in researching difficult or interesting subjects.
5. Understands importance of data reporting and interacts appropriately with physicians and other departments to obtain the documentation necessary for accurate code assignment.
6. Updates knowledge base annually in the following areas: ICD-9-CM, CPT-4 payment regulations for all payers types, coding conventions/rules as published in the "Coding Clinic, and changes in medical terminology and advances in medical and surgical procedures.
Job Qualifications
Minimum Qualifications: Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying. Education: High School diploma or GED equivalent
Experience: Two (2) years of progressively responsible and directly related work experience
Licensure/Certification: Certified Coding Specialist (CCS)
Knowledge, Skills, and Abilities
Ability to adapt to changes and set priorities to meet tactical plans
Ability to comply with the American Health Information Management Associate's Code of Ethic and
Standards and applicable Uniform Hospital Discharge Data Set (UHDDS) standards
Ability to establish and maintain effective working relationships
Ability to manage, organize, prioritize, multi-task and adapt to changing priorities
Ability to plan and organize work to meet deadlines
Ability to solve technical and non-technical problems
Ability to use computer to accomplish data input, manipulation and output
Ability to utilize the ICD-9-CM & CPT-4 coding conventions to code medical record entries; abstract information from medical records; read medical record notes and reports; set accurate Diagnostic
Related Groups
Ability to work effectively through and with others
Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
Knowledge of health information systems for computer application to medical records
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Job Detail Inpatient Coding Specialist-MCH HIMS position
Job Title Inpatient Coding Specialist - MCH HIMS
Job # 12398
Department Name HIMS Coding
Hospital MCH
Job Type Full Time
Schedule Monday - Friday
Job Description
The Coding Specialist is responsible for coding and abstracting inpatient records utilizing ICD-9 diagnosis and procedure codes, in accordance with coding conventions and
guidelines. This requires thorough review of the medical record to validate assigned codes, assure optimum reimbursement and accurate abstraction of required data. Must be able to recognize when further documentation is necessary for accurate code assignment and appropriately query the physician (or others) for clarification, onsite or Remote work available within the state of Texas only. Essential Functions
1. Demonstrates a high degree of independence in performance of responsibilities, working effectively without direct supervision.
2. Demonstrates competency in coding and abstracting all patient types in accordance with ICD-9 and
CPT coding conventions and national coding guidelines, meeting the expected monthly quality and productivity standards according to departmental policy.
3. Maintains an understanding of regulations, standards and practices as they relate to Health
Information Management.
4. Participates in continuing education opportunities and shows initiative in researching difficult or interesting subjects.
5. Understands importance of data reporting and interacts appropriately with physicians and other departments to obtain the documentation necessary for accurate code assignment.
6. Updates knowledge base annually in the following areas: ICD-9-CM, CPT-4 payment regulations for all payers types, coding conventions/rules as published in the "Coding Clinic, and changes in medical terminology and advances in medical and surgical procedures.
Job Qualifications
Minimum Qualifications: Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying. Education: High School diploma or GED equivalent
Experience: Two (2) years of progressively responsible and directly related work experience
Licensure/Certification: Certified Coding Specialist (CCS)
Knowledge, Skills, and Abilities
Ability to adapt to changes and set priorities to meet tactical plans
Ability to comply with the American Health Information Management Associate's Code of Ethic and
Standards and applicable Uniform Hospital Discharge Data Set (UHDDS) standards
Ability to establish and maintain effective working relationships
Ability to manage, organize, prioritize, multi-task and adapt to changing priorities
Ability to plan and organize work to meet deadlines
Ability to solve technical and non-technical problems
Ability to use computer to accomplish data input, manipulation and output
Ability to utilize the ICD-9-CM & CPT-4 coding conventions to code medical record entries; abstract information from medical records; read medical record notes and reports; set accurate Diagnostic
Related Groups
Ability to work effectively through and with others
Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
Knowledge of health information systems for computer application to medical records