Job Summary: Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases/Current Procedural Terminology (CPT). Requires skill in the accurate sequencing of diagnoses/procedures. Ensures that records are coded in an accurate and timely manner.
Demonstrates Competency in the Following Areas:
Ensures that records are coded in a timely and accurate manner. The goal is to ensure the following record types are coded within the requisite timeframes; Inpatient three (3) business days and Outpatient five (5) business days post discharge.
Reviews medical record thoroughly to ascertain all diagnoses/procedures are coded and sequenced correctly, resulting in accurate DRG/APC assignment when applicable.
Contacts responsible physician in a professional, tactful manner, if diagnosis/procedures are not present in the medical record and generate queries for any diagnoses/procedures where further clarification is required.
Serves as a backup for running a report of outstanding uncoded accounts. This should occur a minimum of weekly, if not more frequently.
Codes all diagnoses/procedures in accordance to ICD-10-CM/PCS/CPT coding principles and guidelines.
Reviews and corrects errors in the billing SSI Rejection Queue.
Adds and adjusts charges as needed.
Monitors organizational email and other internal communication mechanisms.
Meets productivity and quality standards requiring 95% accuracy in assignment of principal diagnosis and secondary diagnoses/procedures both in ICD-10/CPT.
Cross training encompasses the coding of all patient types beginning with outpatient. Inpatient coding starts with the training for OB and Newborn cases and progresses to the coding of all inpatients. The inpatient volume may not support all coders to be thoroughly trained in inpatient coding, so those coders with the most experience and clinical knowledge should be cross trained first.
Stays abreast of all coding changes and updates.
Assists the Lead Coder or Director of HIM with state requirements and reports as required.
Enhances professional growth and development through participation in educational programs, current literature, inservice meetings and workshops; shows responsibility for own professional practice and ongoing education. Ensures all required CEUs are completed in order to maintain AHIMA/AAPC credential(s).
Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
Acts as a resource person to hospital staff for coding and may provide education regarding coding changes/issues.
Must be familiar with all medical record and coding requirements, including pediatric and geripsychiatric.
Maintains a good working relationship within the department, other departments and medical staff.
Supports and maintains a culture of safety and quality.
Performs other duties as assigned by the Lead Coder or Director of HIM
Performs performance improvement functions through data collection and documentation review.
Requirements:
Professional Requirements:
Adheres to dress code, appearance is neat and clean.
Completes annual education requirements.
Maintains regulatory requirements, including all federal, state, local regulations and accrediting organization standards.
Maintains patient confidentiality at all times.
Reports to work on time and as scheduled, completes work within designated time.
Wears identification while on duty, uses computerized punch time system correctly.
Completes inservices and returns in a timely fashion.
Attends annual review and department inservices, as scheduled.
Attends 12 staff meetings annually, or reads and returns all monthly staff meeting minutes.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Complies with all organizational policies regarding ethical business practices.
Educational Requirements:
High School graduate or equivalent. Associate's degree preferred.
Current coding certification by the AAPC and/or AHIMA required within one (1) year of employment.
Language Skills:
Able to communicate effectively in English, both verbally and in writing.
Additional languages preferred.
Skills:
Extensive knowledge of ICD-10 diagnosis coding, including guidelines, Coding Clinic and other industry reference sources.
Strong clinical knowledge related to chronic illness diagnoses;
Excellent understanding of clinical documentation requirements in order to support an active diagnosis;
Knowledge of medical terminology, anatomy & physiology, and medical prescription & over-the-counter drugs used to treat conditions required;
Exemplary attention to detail and critical thinking skills;
Excellent knowledge of medical record review and abstraction;
Basic computer knowledge
Ability to work independently as this position can be remote
Physical Demands:
Normal hospital environment. Close eye work. Hearing within normal range. Oral communication. Operated computer, copier, and printer. Frequent sitting. Occasional walking, bending, climbing. May lift and carry up to 15 pounds. May push/pull up to 50 pounds.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.
Seniority level
Entry level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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