Outpatient Coder II

Job Title

Accurately codes and abstracts outpatient medical records for reimbursement and statistical purposes using established coding guidelines. Reviews coding and amends coding edits to assure compliance with all applicable regulations.

Responsibilities:

1. Codes all outpatient medical records in a timely and accurate manner according to department policy.
2. Defines and transforms verbal descriptions of diseases, injuries, and procedures into numerical designations (codes) using ICD-10-CM and CPT-4 according to established coding guidelines.
3. Initiates a physician/department query when there is conflicting, incomplete, or ambiguous documentation in the record or additional information is needed for accurate coding.
4. Enters all required information accurately into computer system for reimbursement and statistical purposes. As applicable based on facility workflow, independently reconcile charges for areas of responsibility. Uses patient schedule together with billing slips to identify missing charges. researches and resolves discrepancy so charge keyed reflect services delivered.
5. Performs ICD-10-CM diagnostic and CPT-4 coding at a minimum accuracy rate of 95%.
6. Remains abreast of all applicable Federal, State, regulatory and hospital-specific coding guidelines.
7. Applies applicable guidelines to all cases coded to ensure accuracy of selected codes.
8. Accesses and research applicable reference materials to further support decision-making in code selection.
9. Participates in Performance Improvement/Quality Assurance activities.
10. Reports on software and hardware problems.
11. Attends required educational sessions (webinars, conferences etc.) to maintain and enhance coding certification(s)
12. Maintains and Model the Organizations values.
13. Demonstrates regular, reliable and predictable attendance.
14. Performs other duties as required.

Education Skills Experience:

Basic familiarity with MS Office applications (Word, Excel. Outlook)

Usage of coding manuals and regulatory websites for research

Certification from the America Academy Professional Coders (AAPC) or the American Health Information Management Association (AHIMA):

CPC, CPC-H, CCS, CCS-P, RHIA, RHIT, or specialty certification required.

Working Conditions:

Manual: significant manual skills/motor coord & finger dexterity

Occupational: Some occupational risk

Physical Effort: Medium to Heavy effort. May exert up to 35 lbs. force

Physical Environment: Some exposure to dirt, odors, noise, human waste, etc.