Division: Compliance

Job Title: Coder III

Job Code:562

Position Summary

Codes and abstracts Inpatient and Outpatientmedical records for the purpose of reimbursement, research, statistical data gathering, and compliance with applicable State and Federal regulations utilizing ICD-10 and CPT coding systems. In addition to performing the essential functions listed below, may also be assigned other duties as required.

Statement of Accountability

Reports to: Coding Compliance Manager

Qualifications

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

• Other qualifications, miscellaneous

Specify if qualifications are Required or Preferred

1. Education

Required:

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

2. Licenses/Certifications

Required:

• Registered Health Information Technician (RHIT)and Certified Coding Specialist (CCS).

Desired:

• Registered Health Information Administrator (RHIA).

3. Work Experience

Required:

• Previous ICD-10 coding experience in the Inpatient Hospital environment.
• Knowledge of medical terminology.
• Minimum of three (3) years of experience in ICD-10 Inpatient coding.

Desired:

• Previous Health Information Management Department experience.
• Experience with electronic medical records.
• 4 - 5 years of experience in ICD-10 Inpatient coding and 1-2 years of experience in CPT coding.

4. Skills/computer/specific technical

Required:

• Working knowledge of ICD-10 and CPT guidelines, conventions, and coding systems.
• Working knowledge of data collection systems for medical records.
• Familiarity with Joint Commission, OSHPD and Title 22 regulations regarding medical records.
• Ability to prepare written reports clearly and timely.

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 Inpatient medical records and assigns appropriate diagnoses and procedure codes using the ICD-10 coding system.
2. Determines, records, and abstracts other required data according to applicable State, federal, or hospital requirements.
3. Requests any definitive diagnoses from physicians using the query process when information is incomplete.
4. Codes 3 Inpatient medical records per hour.

Demonstrates Skill

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

1. Codes records with 97% accuracy rate; performs DRG assignment as appropriate, with accurate case mix index data.
2. Records abstracted data in accordance with published standards with 97% accuracy.
3. Submits accurate and non-leading physician queries.
4. Adheres to coding guidelines and regulations.

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. Maintain professional certifications.
3. 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:

4/11, 9/15, 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.