Coder III

Under the general direction of the Coding Coordinator, Health Information Services, This position's primary responsibility is the coding of all hospital discharges or clinic visits for the purpose of reimbursement, research and compliance with all federal regulations using the ICD-10-CM classification system and CPT 4 procedural codes.

• Chart Review & Coding
  • Identifies and codes hospital all coding work types for the purpose of reimbursement, research and compliance with federal regulations according to diagnosis, operations, and procedures using the ICD-10 CM classification system via in house encoding system.
  • Codes inpatient and outpatient records for billing purposes and data retrieval using ICD-10 CM and CPT 4 classification systems via the in-house encoding system.
  • Thoroughly reviews the entire medical record as part of the coding process in order to assign and report the most appropriate codes.
  • Adheres to all official coding guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS and NCHS).
• Abstracting
  • Abstracts statistical data from the hospital records utilizing encoder or abstracting program. Responsible for ensuring the proper discharge disposition is coded and abstracted.
• Documentation/Compliance
  • Follows up on incomplete records with the Coordinator. All records must meet Medicare, Medicaid and hospital rules or regulations.
  • Communicates as needed with the Coordinator of any information that needs to be clarified in order to accurately code and abstract patient information.
  • Must meet 95% quality coding indicators monthly in 12 months. Quality indicators include but are not limited to billing issues, keying errors, abstracting errors, coding errors, discharge disposition incorrect etc. Other Duties
  • Ability to work all inpatient and outpatient edits.
  • Performs other related duties as assigned.

One of the following certifications is required: RHIT, RHIA, CCS.

HS Diploma or GED is required; Formal ICD-9-CM and CPT 4 classification training is required.