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Role Description

This role involves reviewing patient records and assigning accurate codes for each diagnosis and procedure on the accounts assigned to the coder.

• Review and abstract patient medical records, reporting diagnoses, treatments, and procedures for CAH facility medical services.
• Perform coding duties of discharged patient medical records using various coding guidelines.
• Correctly assign ICD-10-CM/PCS and CPT/HCPCS codes creating APG group assignments.
• Abide by the standards of American Health Information Management Association (AHIMA) Standards of Ethical Coding.
• Apply accurate charges.
• Query physicians when documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Report unusual findings to the supervisor when coding.
• Ensure code assignment is supported by provider documentation.
• Maintain professional competency and knowledge of third-party payer and QIO regulations.
• Compliant with HIPAA, demonstrating discretion and integrity.
• Ability to work with minimal supervision.
• Other duties as assigned.

Qualifications

• A minimum of high school diploma plus successful obtainment and maintenance of the AHIMA credential Certified Coding Specialist (CCS) and/or CSS-P, Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
• Knowledge of and demonstrated appropriate use of ICD 10, ICD 10 PCS, and CPT coding.
• Two years of coding and abstracting experience in ICD-9 CM/ ICD10-CM and PCS, DRGs and CPT including modifiers and APCs.
• Certificates: Certified Coding Specialist (CCS), CCS-P, RHIT or RHIA.
• Thorough knowledge of the related Prospective payment systems (PPSs) and CAH payment methodology.
• Broad knowledge of pharmacology indications for drug usage and related adverse reactions.
• Knowledge of ancillary testing (laboratory, X-ray, EKG).
• Knowledge of anatomy, physiology and medical terminology.
• Understanding of coding practices and guidelines.
• Experience with PC, 3M encoding systems.
• Auditing skills for coding quality and compliance.
• Strong process management skills.
• Good communication skills in working with the public as well as co-workers.
• Basic knowledge of MS Excel.

Requirements

• Light Work: Exerting up to 20 pounds occasionally, and/or 10 pounds of force frequently, or negligible constantly.
• Walking or standing to a significant degree or sitting constantly and pushing/pulling controls.

Interpersonal Relationships

• Supervision Received: HIM Manager
• Supervision Exercised: None
• Other: Hospital personnel, medical staff, other medical facility personnel, some public/patients

Exposure to Hazards

• According to OSHA standards, this position is classified as low risk with little or no risk of exposure.

Equipment Used

• Computer
• Copier
• Fax Machine
• Phone
• Printer