Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-9-CM, and/ or ICD-10- CM/PCS for billing, internal and external reporting, research, and regulatory compliance while maintaining an accuracy rate at or above 95%. Under the direction of the HIM Director, the coder will accurately code inpatient conditions and procedures as documented in the ICD-9-CM and/ or ICD-10 CM/ PCS Official Guidelines for Coding and Reporting. Outpatient coders will accurately code outpatient medical records (for example, diagnostic, therapeutic, emergency department services, ambulatory surgery (same day surgery), and observation service encounters) conditions and procedures as documented in the ICD-9 and/ or ICD-10 Official Guidelines for Coding and Reporting as well as a rules and guidelines for use of CPT and HCPCS codes and modifiers.
Coders will resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors. Work collaboratively with HIM Staff, Clinical Documentation Specialists to ensure the most accurate and complete documentation to support accurate coding/billing.

A.Education/Skills

• High School Diploma or GED
• Preferred completion of Accredited Associate HIM Program, Accredited Baccalaureate or Master’s Health Informatics/HIM Program Degree in Health Information Management or other allied health degree or an AHIMA approved Coding Certificate Program or successful Completion of Coder Certificate Program

• Two (2) years’ progressive on-the-job experience coding with ICD-9-CM and/or ICD-10-CM and CPT-4 coding in a hospital or outpatient setting

• RHIA - Registered Health Information Administrator (AHIMA),
• RHIT - Registered Health Information Technician (AHIMA),
• CCS - Certified Coding Specialist (AHIMA),
• CPC-H - Certified Professional hospital outpatient facility (AAPC),
• CCA - Certified Coding Associate (AHIMA),
• CPC® - Certified Professional Coder (AAPC)