Title:Inpatient/Outpatient Coder - Certified
Reporting Relationship:Health Information Manager
General Summary of Responsibilities:
The employee is responsible for analyzing medical records in order to code and abstract medical information for inpatient/outpatient encounters both medical and surgical using correct codes from ICD-9-CM, and/or ICD-10-CM Diagnosis AND Procedure/PCS AND CPT coding guidelines to be submitted for financial reimbursement as required for the Uniform Bill and for the DRG (Diagnosis Related Group). All Coding Guidelines are to be utilized and adhered to. Assign appropriate CPT codes and modifiers as well as CPT anesthesia codes. Assign codes using the 3M encoder with finalization/releasing of records in Healthland system. Knowledge of using encoder as well as ICD-9-CM; ICD-10-CM and ICD-10-PCS and CPT coding books. Correctly sort the records after coding for doctors boxes for final signatures or refer to Electronic Medical Records Technicians for scanning into the EHR.
Essential Job Functions:
1. Know how to use the Healthland Centriq and 3M encoder Computer Systems for coding and
releasing of records for billing purposes. Know how to access the electronic health record in the Transcription module to review documentation for coding purposes.
2. Correctly code inpatient/outpatient encounters both medical and surgical following Coding
Guidelines for ICD-9-CM; ICD-10-CM and 10-PCS; and CPT coding. Assign all appropriate codes for diagnosis, Procedures, CPT and modifiers on a daily basis. Interact with physicians when further clarification of diagnosis(e) is needed utilizing physician-coder communication form. Maintain quality and quantity of coding as stated in HIM Coding Policy & Procedure.
3. Assign correct DRG for inpatients. Check inpatient and outpatients for correct charges in
Healthland Centriq system before releasing record. Coordinate coding with chart auditing to insure the necessary charts that need to be audited are audited prior to coding.
4. Answer telephone and handle requests or refer to appropriate person for handling.
5. Perform pertinence or concurrent reviews of inpatient charts while on the PCU. Enter the information into the Review Record Assistant for reporting purposes. Re-analyze inpatient records for completion and checking them in or out as needed. Retrieve records when requested.
6. Do quality reviews as directed by Quality Team Leader or Quality Review Committee.
7. Abide by the American Health Information Management Association Standards of Ethical Coding.
Other Job Functions:
1. Perform other related duties as assigned or requested.
Job Qualifications:
Education:
Required: High School Graduate or equivalent, Health Information Management classes
from secondary level institution..
Preferred: Completion of HIM Associate Degree and/or pass the exam for CCS or RHIT National Exam.
Experience:
Required: Knowledge of medical terminology and ICD-9-CM, ICD 10-CM and PCS
And CPT Coding guidelines.
Preferred: Knowledge of ICD-9-CM, ICD-10-CM and PCS, and CPT Coding guidelines.
RHIT, or CCS. Have at least two years previous coding experience or medical coding classes, Anatomy and Physiology; medical terminology.
License/Certifications:
Preferred: Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS)
Personal Skills:
1. Able to work under stress.
2. The ability to work in spite of interruptions, noise and stress.
3. The physical and mental ability to complete the work.
4. Must maintain confidentiality at all times.
5. Ability to interact with other employees, other department personnel and outside agencies.
6. Oral and written communication skills.
7. ICD-9-CM; ICD-10-CM and CPS; and CPT Coding Guideline knowledge.
8. Abide by the American Health Information Management Association Standards
Of Ethical Coding.
9. Be a self-starter with the ability to work with minimal supervision once trained.
10. Uphold the Hospital's values of Safety, Excellence, Compassion, Integrity, Devotion and Teamwork.
Essential Technical/Motor Skills:
Ability to understand the operation of the hospital computer systems and electronic health record including various Health Information, Transcription, Scanning, and Patient Management modules, a software package for release of information and scanning equipment.
Essential Mental Abilities:
Ability to: Independently analyze problems, determine correct course of action and carry out in an appropriate time frame. Prioritize and multitask. Be a team player and willing to share release of information knowledge and guidelines within department. Take initiative to problem-solve and seek ways to do things better. Critical thinking skills are required. Able to work independently, analyzing and assessing while following established policies and procedures and making decisions on the use and disclosure of protected health information.
All offers of employment are subject to a background check and drug screen.
EOE
To protect the health and safety of our patients, residents, employees, family members, and the communities we serve, BBGH has implemented a universal COVID-19 vaccination requirement for employees, care partners and onsite vendors.
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