Coder II

Overview

Coder II Facility HB, Inpatient Coding

40 hours per week, day shift

JOB SUMMARY: Responsible for the coding of medical information into the WakeOne medical records abstracting system and for monitoring completion of the coding function through established best practice processes, professional and regulatory coding guidelines. Assigns ICD CM/PCS codes (Inpatient) and ICD CM/CPT codes (Outpatient) as directed for respective encounters. Reviews and edits associated facility charges as directed for the encounters assigned. Data reported is used for statistical, financial and billing purposes and to meet licensure requirements.

EDUCATION/EXPERIENCE: Graduation from an accredited medical coding program and two years' experience as a Coder I in an acute care facility or a similar position in another facility with demonstrated competency of knowledge base. Satisfactory completion of college level courses in anatomy, physiology and medical terminology preferred. EPIC health information system experience preferred.

LICENSURE, CERTIFICATION, and/or REGISTRATION: Coding certification CCA, CIC, CPC-H, CPC, CCS, RHIT, or RHIA required.

ESSENTIAL FUNCTIONS:
1. Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards.
2. Applies correct ICD CM/PCS (Inpatient) and ICD CM/CPT codes (Outpatient) guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity.
3. Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded.
4. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
5. Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation.
6. Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy. Brings identified concerns to Manager Coding for resolution.
7. Assigns the MS DRG and MCC/CCs that most appropriately reflects documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department (Inpatient).
8. Reviews department-specified reports daily to identify charts that need to be coded based and prioritizes as per department-specific guidelines and within designated timelines.
9. Follows up to ensure that any edits that prevent an account from dropping are corrected within established timelines.
10. Produces specific reports on a monthly basis per established parameters.
11. Responds to inquiries from Patient Accounts or other departments as requested. Communicates with Manager when trending request volumes impact productivity.
12. Participates in on site and/or external training workshops as opportunities arise; maintains credentials, if applicable, and submits written evidence of maintenance.
13. Participates as a member of the Clinical Documentation Management Program.
14. Performs administrative duties in support of the overall coding function as assigned and assists Managers as requested.

SKILLS/QUALIFICATIONS:

• Ability to concentrate for extended periods.
• Knowledge of medical terminology and basic anatomy, physiology, pathophysiology, and pharmacology with ability to apply knowledge to the coding process.
• Demonstrates skill in coding classification systems, diagnosis, procedure selection, and sequencing guidelines.
• Knowledge of APC prospective payment system.
• Demonstrates competence in coding and correct extrapolation of official coding and select billing guidelines to specific coding situations.
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate code assignment.
• Demonstrates full understanding and is compliant with correct coding initiative guidelines, regulatory requirements regarding coding of medical information including but not limited to external regulatory agencies such as Quality Improvement Organizations (QIOs), the Centers for Medicare & Medicaid Services (CMS), other payers, and the Joint Commission.
• Ability to apply broad guidelines to specific coding situations; independently utilizing discretion and a significant level of analytic ability.
• Effective verbal and written communication and customer service skills.
• Ability to operate multiple Windows based software applications.
• Ability to solve problems, close attention to detail, make decisions independently, and manage multiple demands.
• Demonstrates continuous learning as evidenced by personally developed reference materials, online publications etc., to stay abreast of new and revised guidelines, practices and terminology, for reference and application.

WORK ENVIRONMENT:

• Clean, comfortable, well-lit area
• Moderate noise environment