Division: Compliance 

Job Title: Coder I 

Job Code:504 

Position Summary

Codes and abstracts Outpatient Department / Clinic medical recordsfor the purpose of reimbursement, datacompilation, and to ensure compliance with applicable State and Federal regulations utilizing ICD-10and CPT coding systems. In addition to performing the essential job responsibilities listed below, may also be assigned other duties as required. 

Statement of Accountability 

Reports to: Coding Compliance Director 

Qualifications 

• Education
• Licensure
• Work Experience
• Skills/computer/ specific technical

• Other qualifications, miscellaneous

Specify if qualifications are Required or Preferred 

1. Education  

Required: 

• High school graduate.

Desired: 

• Associate of Arts (AA) or Associate of Science (AS) degree in Health Information Technology.

2. Licensure/Certification:  

Required:  

• Certified Coding Assistant (CCA)

Desired:  

• Certified Coding Assistant (CCA), Certified Coding Specialist (CCS)orCertified Coding Specialist – Physician Based (CCS-P) credentials.

3. Work Experience: 

Required:  

• Previous ICD-10 and CPT coding experience in the Outpatient Hospital or Clinic environment.
• Knowledge of medical terminology.
• Minimum of one (1) year of experience in ICD-10 and CPT Outpatient coding.

Desired: 

• Previous Health Information Management Department experience.

4. Skills/computer/specific technical  

Required:  

• Working knowledge of ICD-10 and CPT guidelines, conventions, and coding systems.
• Familiarity with applicable laws regarding confidentiality of patient information.
• Excellent organizational skills and ability to work well independently.

5. Other qualifications  

• Ability to work well and communicate effectively with persons of varying educational and cultural backgrounds

Essential Job Responsibilities 

Achieving Results 

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity 

1. Codes Outpatient and Clinic medical records by assigning appropriate diagnoses and procedure codes using ICD-10 and CPT coding systems.
2. Abstracts other required data according to applicable State, federal, or hospital requirements.
3. Requests any definitive diagnoses from physicians when information is incomplete.
4. Codes 7 outpatient surgery or 12 clinic records per hour.

Demonstrates Skill 

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety 

1. Codes records with a 97% accuracy rate.
2. Records abstracted data in accordance with published standards with 97% accuracy.
3. Submits accurate and non-leading physician queries.

Planning & Coordinating 

Key Components: delegates, decision making, problem solving, management of resources 

1. Communicates changes in work volume and backlog to supervisor.

Professionalism 

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality 

1. Displays good judgment and a practical approach to problem solving.
2. Complies with hospital’s Patient First ethic at all times.
3. Maintains confidentiality of all hospital information. Safeguards protected health information from any intentional or unintentional disclosure.
4. Demonstrates teamwork and responds promptly to requests for helpfrom co-workers.
5. Displays courtesy to others at all times. Is considerate of others’ cultural and spiritual needs.
6. Reports to work as scheduled, in compliance with hospital attendance and punctuality policies.

Improving the Organization 

Key Components: performance improvement, quality initiatives 

1. Participates in performance improvement activities as required.
2. Follows safety policies at all times, helps to maintain a safe workplace.

Self-Development 

Key Components: maintain license/certification, education and training 

1. Completes annual mandatory events as required.
2. Works to improve knowledge on an ongoing basis.

Regulatory Compliance 

Key Components: JCAHO, Title 22, OIG, HIPAA, State/Federal laws, hospital policies 

1. Complies with all applicable laws and standards in regards to confidentiality, privacy and security.
2. Complies with department and hospital policies and procedures.

Prepared by: 

Title:  

Director of HIM 

Date:  

Approved by: 

Title:  

Associate Admin./CNO 

Date: 

Personnel Office Review: 

Date: 

Revised Date: 

5/11, 11/15, 1/16 

Lifting Objects/Patients 

Back Injuries 

Hernias 

Understand A&P of back, causes of back pain, preventive approaches, use of aids when lifting. 

Preventive measures when lifting and use aids when lifting. 

Slip/Trip/Falls 

Contusions, Sprains, Strains 

Avoid undue speed. Use handrails. Clean up spills immediately. 

Fires & Natural Disasters 

Burns & All Types of Injuries 

Recognize possible causes of fires. Smoking materials, faulty equipment. Employees should educate patients. Compressed gasses are flammable & under pressure so must be handled with care. Workers need to be familiar with disaster plans and know exit routes. 

Electrical Hazards 

Shocks & Burns 

Be aware of unsafe equipment and appliances. Attend electrical safety classes and seek assistance if any unsafe areas are noted. 

Assaults 

Minor Injury to Death 

Employees need to be cognizant to potential dangers to ensure safety. Awareness of existing security measures and defensive behavior can protect employee from assaults. 

Needles & Sharps 

Cuts, Punctures, Lacerations 

Sharps should be discarded in designated containers. Employees should exam & handle soiled linens & similar items as if they contained hazardous items. 

Obstacles & Broken Objects 

Abrasions, Contusions, and Lacerations 

Arrange furniture to allow free movement about the room. Keep doors & drawers closed when not in use. Clean/discard broken objects properly (i.e. broken glass should be swept up - not picked up with fingers). 

Possible Exposures to Infections Hepatitis/Tuberculosis/Cytomegalovirus/Varicella/AIDS/Herpes/Staph Infections, Lice/Scabies/Rubeola 

Infection 

Use Infection Control procedures as defined in Infection Control manual. These include handwashing, protective clothing, knowing the risks. Label linens and wastes properly. 

Possible exposure to acids & other chemicals used within the hospital 

Refer to MSDS's 

Employees should follow procedures as explained in their department Hazardous Material training and refer to MSDS's before using/handling any chemical. Follow procedures and do not use any chemical without proper labeling. 

Latex 

Dermatitis to death 

Alert supervisor if you feel that you are allergic to latex materials. Use non-latex gloves for sterile procedures. 

Soaps, Detergents, Cleaning Solutions 

Dermatitis 

Follow Departmental procedures. Protective clothing is available if Dept. is unable to substitute agents that do not cause dermatitis. 

Ergonomic Problems 

Wide Variety of Musculoskeletal nervous disorders 

Body mechanics, positioning of equipment/furniture, and repetitive actions can cause employees to experience a variety of physical problems. Employees should follow safe body mechanics as described in hospital education. Employees are encouraged to seek assistance from their supervisor if they feel a task is causing them to experience physical problems. Work site evaluation may be indicated and this should be discussed with manager. 

Possible Chemical Exposure 

Refer to MSDS's 

Employees work with a variety of chemicals within the lab setting. Employees receive training upon hire and also are expected to review the Chemical Safety Plan yearly. Employees are expected to follow safe working procedures as instructed. 

Possible exposure to radiation 

Sterility, Cancer, Shortened Life Expectancy 

When appropriate, employees should wear film badges (they are monitored routinely) and use lead aprons, gloves, or shields. Identify and appropriately manage radiation therapy patients and their secretions. 

Possible Exposure to Chemotherapeutic Agents 

Refer to MSDS's 

Employees involved in preparation or administration of chemotherapy drugs have potential for exposure. Employees must undergo training in their department and should follow procedures as directed. 

Exposure to Video Display Terminals 

Eye strain & stress in addition to ergonomic complaints 

It is unknown if significant visual dysfunction results from long-term use of VDT's. Problems may be controlled with control of lighting and glare, the color contrast, and workers should have adequately corrected vision. Employees should seek assistance from their supervisor if they feel VDT is causing problems for them.