Certified Surgery/Observation Coder

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Position Summary

• Reviews provider documentation and revises and/or assigns ICD-10-CM codes

and CPT/HCPCS codes as appropriate, based on official coding guidelines.

Researches and takes appropriate action on any coding/claim edits.

• Coding focus is complex outpatient hospital based (Observation, Emergency

Department, Wound, Ambulatory Surgery) or provider based complex procedural

services (surgery, procedures, wound).

Principal Accountabilities

• Standards of Performance: Respect, Integrity, Compassion, Collaboration,

Stewardship, Accountability, Quality

Education

• High School Diploma required. Preferred Associate or Bachelor Degree in

Health Information or a healthcare related discipline.

Licenses and Certification

• Required:

o RHIA, RHIT, or CCS (hospital)

o RHIA, RHIT, CCS, CCS-P, CCA, or CPC (provider based)

Experience and Skills

• Hospital & Provider Based:

o RHIA, RHIT, CCS – None.

• Provider Based:

o CCS-P, CCA, or CPC – 3 years procedural coding required.

Physical Activities

• Intermittent hand manipulation required

• Intermittent lifting and carrying of 20 pounds

Role Specific Responsibilities

o Follows all coding policies, procedures, standard operating procedures

o Effectively uses encoding software and reference materials to assign

appropriate codes.

o Provider driven coding: Reviews and accepts or revises code selection

based upon documentation and coding guidelines.

o Non – provider driven coding: Reviews provider documentation and

assigns appropriate codes based upon coding guidelines

o Reviews coding edits and accurately resolves so encounter can be sent to

claims.

o Sends clear, respectful communications to provider inbasket or queries

when additional information is needed before finalizing coding.

o Identifies and communicates to Coding Lead/Supervisor/Manager any

issues related to documentation, coding or systems that may impact

quality, compliance, or productivity

o Performs work que duties as assigned by Coding

Lead/Supervisor/Manager.

o Maintains coding quality and productivity standards

o Actively engages and makes meaningful contribution when participating

in performance improvement initiatives, department meetings and other

meetings as required.

o Maintains required CEU’s

Compensation (Commensurate with experience):

To

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