Coder

• Job Title:	Coder
  Department:	Billing Office
  Reports To:	Director of Revenue Cycle
  FLSA Status:	Non-Exempt
  Date	2/2/2023
  Position Summary

  Well versed in HOSPITAL (non physician)  coding of  ICD-10 PCS (ICD-10 CM ONLY experienced coders should not apply for this position).    This position scope is around hospital/institutional coding where majority of the work will be to review the below type of work:  

  Hospital physician charts, including Surgery, Inpatient DRG/APRDRG classifications, FACILITY emergency room charts (non physician), which include review of labs, discharge summaries, radiology reports, nurses notes, understands how to query a physician, has full knowledge of encoder, present of admission classifications, principal procedure assignments, modifier appendixes, HCPC I and HCPC II knowledge.  

   

  Essential Duties & Responsibilities 

  Assigns codes to diagnosis and procedures of hospital facility records (non physician records), including surgeries, inpatient admits, emergency room visits, observation, utilizing ICD-PCS, Modifiers Appending, HCPC I and HCPC II, DRG assignment,  and CPT code assignment in accordance with ICD Coding Guidelines, CPT Coding Guidelines.   

• Ensures codes are assigned accurately and sequenced correctly ensuring reimbursement is appropriate in accordance with government, insurance, and/or other payer regulations to include the coding of diagnoses and procedures and may include the coding of signs and symptoms if needed to support medical necessity. 

• Identifies, researches, and corrects or routes accounts on the coding and billing edit work queues to meet coding guidelines and facilitate accurate billing.  

• Queries the provider when documentation is determined to be insufficient, conflicting or ambiguous to elicit documentation reflecting the most accurate and specific conditions or procedures.  

• Maintains productivity and quality standards set forth in the Districts outpatient coding standards. 

• Utilizes online and hard copy coding reference materials. 

• Works closely with Outpatient Coding Supervisor and the health center/clinic medical and nursing staff regarding documentation and notification of charging issues.  

• Demonstrates evidence of professional growth by attending coding workshops, conferences and or seminars, maintaining required C.E. requirements (departmental and professional), and individual study and education regarding coding, reimbursement, and HIM competencies. 

• Performs other job related duties as assigned. 

• Working knowledge and high level of experience with the ICD-10-PCS and/or CPT/HCPCS coding classification systems, MS-DRG's, APC's, POA's, Modifier laterality, HCPC classifications, dependent upon whether an IP, OP, or ER encounter. The physical demands described here are the representative of the minimums that must be met by an employee to perform all essential functions of the job. Most physical demands are below, plus: Frequent: repetitive motion involves approximately 25% keyboard and 75% mouse for data entry 

• Performs other duties assigned 

COMPUTER SKILLS 

•  Intermediate computer skills   

CERTIFICATE/LICENSES 

AHIMA as CCS or by AAPC as COC or CPC.  

KNOWLEDGE SKILLS AND ABILITIES:  

• Must possess knowledge of ICD-10-PCS coding guidelines , CPT/ HCPCS knowledge; Severity of Illness and Risk of Mortality codes; and to Query the Physicians, as appropriate. 

• Prior coding experience in ICD-10-CM  likewise, diagnoses/procedure coding and HCPCS/CPT procedure coding in the acute care inpatient/outpatient hospital or professional services setting of E&M codes or E&M levels.  This aspect of the work is only 10% of the coding, the remaining is all facility/institutional coding. 

• The hospital coding tools are manual and requires the coder to have full knowledge of ICD-PCS coding guidelines, this includes understanding the ICD-10 PCS structure, guidelines which includes:  signs and symptoms, section, body part, approach, device, root operation, body system and qualifiers 

• The hospital charts are not all dictated, but are hand written, the coder must be able to work in a heavily manual environment 

• Must have knowledge of and be able to code all types of patient medical records including: Hospital non physician Inpatient, Outpatient, Emergency Medicine, Behavioral Health, Observation, Infusion and Injections, Edits and Errors and Same Day Surgery. 

• Must be able to achieve and maintain appropriate coding quality and productivity established in the Coding department policy and procedure at 95% proficiency 

• Must have a strong understanding of computer applications and of automated encoder system. 

• Must have knowledge of anatomy and physiology, medical terminology, surgical terminology, pharmacological terminology, patient care documentation terminology. 

• Must have the analytical ability necessary to interpret data contained in records and to assign appropriate codes. 

• Must be able to communicate effectively and have excellent customer service skills. 

• Requires the ability to work well independently and demonstrate independent decision making abilities. 

• Requires the ability to read, write and speak effectively in English.