Coder Certified

Certified Coder Specialist (FT)

Under general supervision and according to established procedures, assigns diagnostic codes to medical record information. Codes charts under the ICD-10-CM and ICD-10-PCS (HCPCS) System for statistical and DRG assignment purposes. Abstracts required data into hospital abstracting system. The outcome of information gathered is used to determine the hospital database and reimbursement of hospital claims. Responsible for timely review of patient records in order to identify an appropriate selection of codes which will accurately reflect the reason for admission, extent of care received, and level of severity of illness.

The evaluation is to assure individual performance, departmental goals and organizational goals are aligned. It is designed to support communication between the manager and the employee. Employee perception of their own performance is very important. To maximize the benefit of this process, both the manager and the employee participate in the evaluation process.

Rating Scale Definition

Needs Improvement – Performance is consistently below requirements/expectations. Immediate improvement is necessary.

Meets Expectations – Performance meets all established standards and sometimes exceeds them. Activities contribute to increased unit/department results. Employees consistently complete the work that is required and at times go beyond expectations.

Excels – Outstanding performance.

Not Applicable – Item does not apply to this job.

Qualifications

A. Knowledge, Skills and Abilities

Excellent customer service skills. Reads and understands the English language. Ability to think critically and analytically with little or no supervision. Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes. Ability to process information and prioritize. Possesses exceptional verbal and written communication skills. Possesses independent work habits, is self-reliant and self-directed. Ability to learn, adapt, and change as required by the job functions. Ability to maintain absolute confidentiality of material and information accessed and reviewed. Basic computer literacy. Ability to move freely, reach, bend, and complete light lifting. Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines. Ability to maintain attendance to meet standard job practices.

B. Education

High School diploma or GED. Equivalent to an associate degree in medical terminology (with course work in medical terminology, anatomy, physiology, disease processes, ICD-10-CM coding and prospective payment) preferred.

C. Licensure

Certified Coding Specialist/CCS. Eligible for designation as a RHIT or RHIA preferred.

D. Experience

One year experience in ICD-10-CM and ICD-10-PCS and CPT-4 coding in acute care facility.

E. Interpersonal skills

F. Essential technical/motor skills

G. Essential physical requirements

Sedentary: Exert up to 10 lb. of force occasionally and/or a minute amount frequently - greater than 75%

H. Essential mental requirements

I. Essential sensory requirements

J. Other

Good verbal, written and computer communications skills. Ability to work harmoniously with others. Detail oriented. Ability to work with physicians in a collaborative manner.

K. Equipment used.

Other Qualifications

A. Exposure to hazards (body fluid exposure level)

Level III

B. Age of Patient Populations Served

No patient contacts.

Job Specific Duties and Performance Standards

Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position's purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.

o Professional Requirements

Maintains regulatory requirements including all state, federal, and Joint Commission regulations related to Health Information Services, as appropriate, to the facility. Always maintains patient confidentiality. Complies with all HIPAA Policies and Procedures, specifically with the use of "minimum necessary information" to perform job duties. Maintains an organized and clean work area. Actively participates in performance improvement and continuous quality improvement activities. Must be familiar with the following Policy and Procedures: Administration, HIS, Infection Control, Emergency Preparedness and Safety, and HIPAA. Ensures compliance with policies and procedures.

o Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures. Assigns proper ICD-10-CM, ICD-10-PCS and HCPCS diagnostic and operative procedure codes to charts and related records by reference to designated coding manuals and other reference material.

Codes a minimum of the following: 3 inpatient records, 3 OPO/ OPS, 12 emergency department records, and 30 other outpatient records per hour.

Maintains within five days after discharge coding requirements.

Applies uniform hospital discharge data-set definitions to select the principal diagnoses, principal procedure, and other diagnoses and procedures that require coding, as well as other data items required to maintain the hospital database.

Verifies that coded information is entered into the database without any errors within five days of patient discharge.

o Applies sequencing guidelines to coded data according to official coding rules.

Assigns DRG code to each record according to healthcare finance-administration directives. Enters coded/abstracted information into DRG grouper, analyzes groupings, and observes for assigned appropriate DRG weight for reimbursement.

Identifies any and all complications or co morbidities.

Utilizes the computerized coding/abstracting equipment appropriately.

Assesses the adequacy of medical record documentation to ensure that it supports the principal diagnoses, principal procedure, complications, and comorbid conditions assigned codes. Consults with the appropriate physician to clarify medical record information.

Identifies any documentation inadequacies with physician and clarifies medical record information.

o Answers physicians/clinicians' questions regarding coding principles, DRG assignment, and prospective payment system. Assists finance data processing, and other departments with coding/DRG issues. Assists physicians and ancillary departments with coding questions with timeliness, courtesy, and tact.

Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature, and so forth.

Utilizes professional affiliations, etc., in order to stay current in professional developments.

Attends all pertinent coding seminars.

Maintains updated coding books.

o Works with the Coding Manager to identify and resolve coding issues. Attends staff meetings as directed by the Coding Manager. Reports all aged accounts to the HIS Supervisor. Works with HIS Staff and/or Physician to obtain all necessary documentation to code all accounts in a timely manner. Maintains a listing of aged accounts and documentation of steps taken to obtain necessary documentation. Keeps Supervisor informed of all aged accounts.