JOB SUMMARY

Under the general supervision of the Operations Manager, the Coder assigns diagnosis and procedure codes to patient medical records and enters coding and abstracting patient data into the facility computer system. Generally, performs coding on all types of cases. Position can be specialized to code inpatient, outpatient, or physician/ professional coding, but must be able to code all patient types depending on business requirement. Appropriately code for International Classification of Diseases 10th Revision-Clinical Modification (ICD-10-CM)/diagnosis, and Procedure Codes such as Current Procedural Terminology (CPT), International Classification of Diseases 10th Revision-Procedure Coding System (ICD-10-PCS) or Healthcare Common Procedure Coding System (HCPCS). related to a patient's admission in order to provide billing and statistical information.

The work of this position is guided by defined policies, guidelines, and established practices and precedents.

The method of chart analysis normally required to solve problems or make decisions is to collect, compile and organize facts, figures and/or other information in accordance with established procedures or as directed by facility policy. This position is responsible to adhere to all federal guidelines as set forth by CMS and State guidelines, and as per coding rules and guidelines set in the AHA Coding Clinics.

The Medical Coder must be able to meet a minimum of 95% quality and productivity target set by the organization or by the client.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Abstracts, codes, and sequences the classification of medical and surgical procedures, diagnosis, and treatment modalities on Inpatient and Day Surgeries.

2. Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions, and surgical procedures.

3. Selects the latest, most accurate and descriptive codes per specialty:

a. For Inpatient specialty

i. ICD-10-CM for diagnosis coding, ICD-10-PCS for procedure coding

ii. Assigns Present on Admission (POA) value for inpatient diagnoses as a supplement for ICD-10-CM coding.

iii. Assigns correct Principal Diagnosis, Secondary Diagnosis especially that are Comorbid Complication (CC) and/or Major Comorbid Complication (MCC)

iv. Assigns correct Diagnosis-Related Grouping (DRG) and perform coding compliance reviews. Follow official coding guidelines to review and analyze health records.

b. For Outpatient and Professional specialties

i. ICD-10-CM for diagnosis coding, CPT for procedure coding and any applicable HCPCS coding

ii. Assigns correct Ambulatory Payment Classification (APC) for facility and perform coding compliance reviews. Follow official coding guidelines to review and analyze health records.

iii. Follows specific guidelines and instructions from the facility, payer and physician.

4. Writes a compliant query to the provider for documentation and coding improvement.

5. Enters codes into computer system, extract required information from source documentation and enter data into encoder and abstracting system.

6. Reports to their supervisor their productivity status and daily issues.

7. Identifies and reports areas of concern with respect to improper coding and documentation.

8. Maintains confidentiality of patient records at all times.

MARGINAL/ADDITIONAL FUNCTIONS:

Contributes to a positive department image by exhibiting professionalism, adaptability, teamwork, and mutual respect with all staff members.

JOB QUALIFICATIONS:

Knowledge and Skills:

Must have an expert understanding of computer applications.
Must have knowledge of coding guidelines and medical terminology.
Requires expert knowledge of automated encoder system.
Must have the analytical ability necessary to interpret data contained in records and to assign appropriate codes and the visual acuity necessary to read and decipher handwriting.
Must also have knowledge of ICD-10 coding systems and MS Diagnostic-Related Groups and APCs.
Must be able to communicate effectively and have excellent customer service skills.
Requires the ability to read, write and speak effectively in English.

Education or equivalency:

Bachelor's Degree in Medical Records or Allied Medical Field, or education courses and equivalent relevant clinical work experience.

Experience:

Requires a minimum of one year of acute care, or ED/Clinic coding experience, six months which were live accounts with a client.
A working knowledge of Inpatient and Outpatient coding requirements.

Certification/licensure:

Certification is dependent on client requirement.
AAPC Coding Certification: CPC, COC, CIC
AHIMA Coding Certification: CCA, CCS-P, CCS