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Outpatient Medical Coder
4 months ago
Outpatient Medical Coder / HIM Coder - Remote
A. Outpatient Rehab Therapy and Wound Care Services
1. Codes all outpatient therapy and wound care records by the third day after admission according to ICD-10-CM and CPT guidelines with 95% accuracy, to include Physical Therapy, Occupational Therapy, Speech Therapy, and Wound Care services.
B. All Record Types
1. Query Medical staff and midlevel providers when code assignments are not straightforward or documentation in the medical record is conflicting, ambiguous, inadequate, incomplete or unclear for coding purposes. Keep medical providers informed of pertinent documentation changes that reflect accurate code assignment.
2. Continuously evaluates the quality of clinical documentation to spot incomplete or inconsistent documentation for outpatient encounters that impact the code selection. Brings identified concerns to HIM Director(s), Coding Manager, and/or Vice President of HIM.
3. Performs necessary investigations/actions to assure the account will drop into the billing system without any problems. Informs Director of any unusual circumstances that could delay coding/billing process.
4. Utilizes 3M coding software/encoder application along with HMS MedHost to assist in accurate coding and clean claims processing. Assures all codes assigned are supported by physician documentation within the medical record.
5. Monitors the billing error report to ensure all accounts are dropped timely and accurately. Communicates all potential billing delays or unusual findings with the HIM Director.
6. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
7. Abstracts designated fields for physician information to assure physician index reports reflect actual activity. Informs Director of any new physician activity.
8. Abstracts other demographic or special study information according to procedure.
9. Works closely with the HIM Director/Business Office regarding billing discrepancies/denied claims pertaining to diagnosis and procedure codes.
10. Attends in-services and educational seminars. Stays informed and current with coding trends, coding rules and guidelines.
11. Cross-trains to assist with Rehab and Wound Care coding along with any additional coding needed.
12. Performs special projects as needed per the Coding Manager.
13. Covers other HIM-related tasks as assigned by Coding Manager.
II. Customer Service
• Must possess interpersonal, written and verbal communication skills required for effective interaction with medical providers, directors of rehab, and wound care managers.
• Must communicate frequently in a tactful and diplomatic manner with medical providers, directors of rehab, and wound care managers, including clear and concise querying.
• Must promote customer satisfaction by way of prompt and courteous service to internal and external customers.
• Promotes the Mission and Vision of PAM Health within the work environment and the community.
• Respects dignity and confidentiality by adherence to all applicable policies and procedures.
• Maintains the highest level of customer service via courtesy, compassion and positive communication.
III. Health and Safety
• Works in a manner that promotes safety; wears clothing appropriate to the performance of the job.
• Participates in OSHA required training.
• Follows universal precautions as appropriate for position; complies with Employee Health requirements for continued employment.
• Reports unsafe practices to management.
• Knows own role in case of an emergency.
POSITION QUALIFICATIONS:
Education and Training:
- High school diploma or its equivalent is required.
- Coding, medical terminology, Anatomy/Physiology courses preferred.
- Certification as one of the following is preferred;Certified Coding Specialist (CCS), Certified Coding Specialist-Physician based (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder Apprentice (CPC-A), Certified Billing and Coding Specialist (CBCS), Certified Coding Associate required (CCA), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN) with ICD-9-CM coding background, Licensed Practical Nurse (LPN) with ICD-9-CM coding background
- Experience as a Coder and currently pursuing any of the above listed credentials will be considered.
Experience:
- Minimum of two (2) years experience as a coder is preferred.
- Knowledge of ICD-10-CM / CPT coding skill, disease processes, medical terminology, anatomy and physiology, pharmacology and laboratory terminology in order to code accurately.
- Ability to stay abreast of coding changes/ICD-10-CM Official Conventions along with Official ICD-9-CM / CPT Guidelines for Coding and Reporting.
- Ability to assign ICD-10-CM diagnosis/procedure codes according to the International Classification of Diseases utilizing the 3M coding application.
- Must possess accurate data entry skills and computer skills. Ability to enter data into the computer for billing and statistical purposes required.
- Must possess ability to communicate with customers, families, staff, management, physicians and general public.
- Must be able to follow directions accurately and timely, produce quality and quantity work of repetitive tasks and have preference for orderly, detail-oriented duties.
- Must have understanding of HIPAA regulations.
- Must exercise initiative and concise decision-making, organize work independently, and be willing to work with physicians and other hospital staff, and promote a positive attitude.
- Familiarity with TJC and State regulations along with legal aspects of the medical record.
Knowledge, Skills, and Abilities:
• Knowledge of ICD-10-CM coding skill, disease processes, medical terminology, anatomy and physiology, pharmacology and laboratory terminology in order to code accurately.
• Ability to stay updated on coding changes.
• Must possess excellent communication, organization and numerical filing skills.
• Must possess good typing and or computer data entry skills.
• Must have ability to maintain confidentiality, exercise initiative and concise decision-making, organize work independently, be willing to work with physicians and other hospital staff, and promote a positive attitude.
• Should be able to follow directions accurately and timely, produce quality work of repetitive tasks and have preference for orderly, detail-oriented duties.
• Must be computer literate and able to use copy and fax machines.
