Medical Records Coder

Job Title

Health Information Management

Job Responsibility

Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.

Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.

Utilizes resources and reference materials (e.g., on-line sources, manuals) to identify appropriate codes and reference code applicability, rules and guidelines.

Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record.

Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures in accordance with the established International Classification of Diseases 10th Revision Procedure Classification System (ICD-10-PCS) Official Guidelines for Coding and Reporting.

Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.

Make determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process.

Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment.

Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations.

For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.

Assigns appropriate discharge physician in the system.

Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations.

Demonstrates basic knowledge of the impact of coding decisions on revenue cycle.

Assists in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity of illness and risk of mortality as indicated.

Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations.

Maintains the minimum data standards for accuracy and efficiency as defined by the facility.

Maintains certified coding credentials in accordance with the certified coding requirements and demonstrates annual compliance.

Performs related duties, as required.

Completes moderately complex assignments that require an ability to recognize the need to occasionally deviate from accepted practices.

Exercises independent judgment on basic or moderately complex issues regarding job and related tasks.

Elevates questions, problems and significant challenges to more senior team members for direction or subject matter expertise on new or unprecedented assignments.

Certain jobs may require frequent transactional interaction with external vendors, partners or clients/patients.

Job Qualification

Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCSP), Certified Inpatient Coder (CIC), or Certified Outpatient Coder (COC), required.

Successful completion of a medical coding course required and minimum of two (2) year experience as an ICD-10 Outpatient/Inpatient medical records coder, in an acute care facility, required.

Competent in the utilization of an electronic medical record, and computerized coding/abstracting systems, required.

Experience with Computer Assisted Coding is preferred.

*Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).