Under the general direction of the Coding Manager and/or Lead,  the Coding Specialist lll is responsible for coding accounts providing high level technical competency and subject matter expertise analyzing 

 physician/provider documentation contained in assigned Complex Outpatient (CO) and/or Inpatient health records to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Provides appropriate Medical Severity Diagnostic Related Groups (MS-DRG), Present on Admission (POA), Severity of Illness (SOI) & Risk of Mortality (ROM) assignments for Inpatient records and accurate APC assignments and all required modifiers for Complex Outpatient records.    

Utilizes encoder software applications, which includes all applicable online tools and references in the assignment of International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis and procedure codes, Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) procedure codes, MS-DRG, POA, SOI & ROM assignments and assignment of APC’s and all required modifiers.  

Assigns appropriate code(s) by utilizing coding guidelines established by: 

•    The Centers for Medicare/Medicaid Services (CMS) ICD-CM Official Coding Guidelines for Coding and Reporting, ICD-PCS Official Guidelines for Coding and Reporting 

•    American Hospital Association (AHA) Coding Clinic for International Classification of Diseases, Clinical Modification 

•    American Medical Association (AMA) CPT Assistant for CPT codes 

•    American Health Information Management Association (AHIMA) Standards of Ethical Coding 

•    Revenue Excellence/RHM Organization coding policies

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.