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Job Title

Job Summary:

To independently and efficiently perform the responsibilities assigning accurate diagnosis and procedures codes to the patients' health information records for: Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), Inpatient (IP) and other selected facility records. Maintain an acceptable level of performance in quality and productivity for ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification and nomenclature systems.

All work will be carried out in accordance with the: International Classification of Diseases - Official Coding Guidelines for coding and reporting as established by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS); American Medical Association (CPT); National Correct Coding Initiative (NCCI); Uniform Hospital Discharge Data Set (UHDDS), Medicaid (OMAP), and organization/institutional coding directives.

Ability to communicate with physicians in order to obtain clarification for diagnoses/procedures. Ability to understand the clinical content of the health record and abstract the data in the patient health information record data as well as perform other duties assigned.

The position requires the new coder to be on-site for one week training or until they meet the departments expectations.

Essential Responsibilities:

• Proficient in medical record review and translating clinical information into coded data. Identify and assign appropriate codes for diagnoses, procedures and other services rendered, while also validating any Computer Assisted Coded (CAC) assignments for dual coding. Utilizing the Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software system for professional surgical services, analyzing and maintaining systems accuracy, validity and meaningfulness for both professional and facility services. Utilizes electronic patient data system and clinical information system (EpicCare) to access patient encounter information. Abstracts and enters clinical data elements as defined by the needs of the organization. Identifies and assigns principal diagnosis and procedure codes, sequencing them as needed for proper Ambulatory Payment Classification (APC), Medicare Severity-Drug Related Group (MS-DRG), All Patients Refined Diagnosis Related Groups (APR-DRG) assignment, utilizing applicable coding conventions. Demonstrates knowledge and understand of CMS HCC Risk Adjustment coding.
• Routinely performs chart analysis to identify areas of the medical record that contain incomplete, inaccurate or inconsistent documentation. Reviews and verifies chart information (i.e. POS, attending provider). Assesses and inputs data. Reviews and verifies component parts of medical records to ensure completeness and accuracy of diagnostic and therapeutic procedures that must conform to CMS coding rules and guidelines. Meets and maintains department standards 95% for productivity and quality.
• Fully utilizes resources available such as, Coding Clinic and CPT Assistant to research issues to apply coding guidelines. Identifies coding concerns and informs supervisors, managers as appropriate. Utilizes query process when appropriate. Assists in implementing solutions to reduce back-end coding errors. Stays current on coding and regulatory publications, attends workshops to stay abreast of current issues, trends, changes in the laws and regulations governing medical record coding and documentation to mitigate the risk of fraud and abuse and to optimize revenue recovery.
• May assist with special projects. Maintain confidentiality and effective working relationships with staff. Communicate in a clear and understandable manner, exercises independent judgment. Reviews annual ICD-10 Official Guidelines for Coding, along with review of quarterly Coding Clinic and monthly CPT Assistant.
• Performs as a team member of Facility Coding Services, and actively participates with peers coding in-services, staff meetings, reporting of performance measures, and quality outcome monitors. May participate in development of organizational procedures. Attends and participates in selected national and regional coding education sessions. Perform other duties as assigned.

Basic Qualifications:

• Minimum two years experience in a directly related coding field or 18 months within the Apprentice program.
• High School Diploma or General Education Development (GED) required.

License, Certification, Registration: The candidate must have 1 from the following list:

• Registered Health Information Technician Certificate.
• Registered Health Information Administrator Certificate.

Additional Requirements:

• Previous experience with EMR patient documentation system with intermediate knowledge and skill in the use of a computer.
• Advance knowledge of disease processes, diagnostic and surgical procedures, ICD-10-CM, ICD-10-PCS, HCPCS/CPT, classification systems, health information/medical record department responsibilities with knowledge of government regulations and areas of scrutiny for potential fraud and abuse issues.
• Advanced knowledge of medical terminology, pharmacology and medial coding principles for ICD-10-CM, ICD-10-PCS, HCPCS/CPT coding.
• Fluent in English, demonstrating skill and proficiency in oral and written communication.
• Skills in time management, organization and analytical skills.
• Ability to manage a significant workload and to work efficiently under pressure meeting established deadlines with minimal supervision.
• Ability to use independent thought and judgement.
• Abides by the Standards of Ethical Coding as set for by the American Health Information Management Association (AHIMA).
• Meets and maintains department standard for performance, productivity and quality.
• Department will furnish final candidate a coding skill test. The candidate will be required to pass with a 75% or better on the test.
• Academic knowledge and working experience performing coding and abstracting responsibilities in health information/medical record services.

Preferred Qualifications:

• Minimum two years of experience in health information/Medical record environment, with facility coding experience that includes Medicare reimbursement guidelines.
• Proficient knowledge and skill in the use of a computer and related system and software to include: EMR(s), Microsoft Office Suite and other software programs.
• Ability to evaluate, analyze, develop information regarding mathematical statistics and percentages that compare finding trends and outcomes related to productivity and /ore medical record audits.
• Extensive knowledge of ICD-10 coding guidelines; with knowledge and demonstrated understand of CMS HCC Risk Adjustment coding and data validation requirements.
• Degree in Health Information Management.

Employee Status: Regular Travel: No Job Level: Individual Contributor Job Type: Standard