Coder (Business Office)

Primary Purpose: To provide customer service to both the internal and external customers of the Health Information Management Department in a timely fashion. Review all outpatient encounters, selecting appropriate ICD-10-CM* and ICD-10-PCS* codes to reflect the diagnoses and course of treatment.                                             

Formal Policy-Setting Responsibilities: No formal responsibility.  The policies associated with the job’s purpose and essential responsibilities are set by others.                                          

Routine Decision Making: Selects ICD-10 CM* diagnostic codes and CPT-4 procedure codes for outpatient procedures, and ICD-10-PCS codes for inpatient procedures to obtain appropriate reimbursement. Coders also verify the correct charges are on the chart in accordance to physicians’ orders.                                      

Formal Supervisory Responsibility: No formal supervisory responsibility.                                              

Required Knowledge: Extensive knowledge of medical terminology, anatomy and physiology.  Working knowledge of ICD10-CM*.                                       

Preferred Skills and Ability: Proficiency in computer skills. Good communication skills with some experience working with physicians. Ability to maintain a high level of integrity and confidentiality of medical information. Strict attention to detail.

Unusual Working Conditions: None.                                      

Education and Certification/ Registration Required for the Position: Coding Certification required. CPC, CPC-H, CCS, and/or RHIT:

PART TWO: Essential Responsibilities and Tasks

A.           Codes records using ICD10-CM* coding guidelines and ICD-10-PCS procedure coding guidelines.  Trucode Encoder. (85% of time)                                                

1.            Determines appropriate ICD10-CM and ICD-10-PCS procedure codes for inpatient procedures and CPT-4 treatment codes for outpatient procedures, utilizing the Trucode encoder for all code selections on outpatient charts assigned.                                                        

2.            Abstracts completed records entering correct information in the required abstract field, with minimal errors, verifying other pre-entered fields bypassed.

3.            Making sure that codes are assigned correctly and sequenced appropriately as per government and insurance regulations.

4.            Complying with medical coding guidelines and policies.

5.            Following all medical necessity edits by communicating with departments on charging, documentation and sending physician queries.

6.            Coders may be involved in audit processes as needed by Health Information Management (HIM)/Coding Coordinator.

B.            Answers phone calls in accordance with departmental standards. (5% of time)

1.            Answers both internal and external phone calls utilizing proper phone etiquette, within three rings, two rings preferred.                                                      

2.            Refers unresolved patient/customer issues to the Health Information Management Coordinator.                                

3.            Forwards calls appropriately 100% of the time.

C.            Prepares records for scanning as necessary (5% of time).                                                            

1.            Prints separator sheets for encounters coded.                                                   

2.            Places separator sheet appropriately with in encounter.

D.            Performs other duties as requested by HIM/Coding Coordinator. (5%of time)

                1.            Meet productivity and quality standards.

2.            Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results.

CPC or similar preferred

Prior coding experience preferred