POSITION SUMMARY:

Assigns appropriate codes to reflect all diagnoses and procedures extrapolated from physician and appropriate nursing documentation during a patient encounter according to the most current coding methodologies, including ICD-10-CM/PCS, HIM-designated CPT-4/HCPCS and CPT-HCPCS modifiers resulting in appropriate reimbursement. Abstracts required data to input into the Medical Center's computerized data base. Converts all patient visits and encounters into appropriate DRG (Diagnosis-related group), ASC (Ambulatory Surgical Classification), APG (Ambulatory Patient Groups), APC (Medicare's Ambulatory Patient Classification) assignments in order to correctly submit the optimal reimbursement for each patient encounter coded.

Position: Medical Coder-U

Department: Clinical Documentation

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Abiding by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adhering to official coding guidelines and departmental procedures, the Medical Coder:

Reviews patient medical records and abstracts medical data that identifies all diagnoses and procedures. Codes diagnoses, procedures, and appropriate modifiers from the medical record documentation using ICD-10-CM/PCS, CPT4/HCPCS classification systems. Refers to a computerized encoding system, written coding aids and other reference materials to ensure accurate coding for billing.
Sequences diagnoses, procedures and complications by following ICD-10-CM/PCS, CPT-4, the Uniform Hospital Discharge Data Set (UHDDS); adheres to the Official Guidelines for Coding and Reporting, Coding Clinic guidelines and other regulatory guidelines as appropriate. Consults with the CDCI team to request appropriate physician or appropriate medical staff to clarify medical record information.
Assigns grouper codes to each record according to patient type and financial class (DRG, ASC, APG, etc.). Enters coded/abstracted information in grouper, analyzes groupings, and assigns the appropriate grouper for appropriate and accurate reimbursement. Data enters abstracted information into the Medical Center's computerized database.
Assists the clinical documentation specialists in medical record documentation auditing as needed. Works closely with other coding staff to resolve coding related issues and denial management.
Maintains productivity standards set forth in Departmental Policies and procedures.
Contacts Medical Records departments to track missing records so that all records can be billed.
Maintains knowledge of coding and professional skills, including maintaining yearly coding credentials through attendance at in-service programs, conferences, workshops, review of current literature and other educational programs.
Assists in training new personnel in department coding procedures.
Utilizes hospital's cultural values as the basis for decision making and to facilitate the hospital's goals and mission.
Follows established Hospital infection control and safety procedures.
Performs other duties as needed.

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required).

JOB REQUIREMENTS

EDUCATION:

Level of knowledge equivalent to that ordinarily acquired through completion of an Associate's Degree in Health Information, Medical Records, Medical Coding or similar program. An equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.

CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:

Must have obtained and maintain current at least one of the following:

Certified Coding Specialist (CCS)
Certified Coding Specialist-Professional (CCS-P)
Certified Professional Coder (CPC)
Certified Professional Coder-Hospital Outpatient (CPC-H)

EXPERIENCE:

At least 12 months of full-time coding experience in an acute care facility.

KNOWLEDGE AND SKILLS:

Work requires in-depth knowledge of medical terminology, ICD-10-CM/PCS and CPT-4 Coding conventions and knowledge of the various DRG systems (CMS DRGs, AP-DRG, and APR-DRGs). Work also requires basic concepts of human anatomy, physiology and pathology.
Strong knowledge of health records, computerized billing and charging systems, Microsoft applications, data integrity, and processing techniques required.
Excellent organizational skills, including ability to multi-task, prioritize essential tasks, follow-through and meet timelines.
Ability to work with accuracy and attention to detail
Ability to solve problems appropriately using job knowledge and current policies/procedures.
Ability to work cooperatively with members of the healthcare delivery team and staff, ability to handle frequent interruptions and adapt to changes in workload and work schedule and to respond quickly to urgent requests.
Must be able to maintain strict confidentiality of all personal/health sensitive information and ensure compliance of HIPAA rules and regulations.

Req id: 28717 Apply