Coder II | UF Heart & Vascular (Jax) | Full-time | Days (REMOTE)

Overview

OverviewThe Coder II position assigns diagnoses and procedure codes to Observation and Same Day Surgery medical records.

Responsibilities

• Assigns correct ICD-10-CM code to all diagnoses and correct CPT code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical record in order to retrieve proper documents (i.e.discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity
• Reads and understands operative reports in order to classify to the most accurate CPT codes.
• Researches complex operations as necessary.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Assigns the correct modifier on CPT codes that are required under the Medicare APC reimbursement.
• Maintains a thorough knowledge of the use of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies.
• Maintains a positive working relationship with physicians in order to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains a thorough knowledge of the prospective payment system and any new codes or DRG's added / changed each year.
• Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as the ICD-9-CM coding conventions, Coding Clinic, and other official resources to substantiate the most appropriate, correct code assignment.
• Stays abreast of Medicare's medical review policies and incorporates updates and changes into the coding process.

Qualifications

Education / TrainingHigh School Diploma / EquivalentPreferences :Graduate of a Health Information Management ProgramExperience Requirements1-year Medical Record CodingCertificates / Licenses / RegistrationAny AAPC or AHIMA Medical Coding CertificationJ-18808-Ljbffr.