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SalaryThe Health Information Management (HIM) Coder is responsible for coding outpatient and inpatient facility surgeries with the appropriate classification systems for purposes of billing, research, statistics, and indexing. This job requires coding, abstracting information, and performing other relevant medical record duties that must be done before payors can be billed.
A bachelor’s degree or associate degree preferred. RHIT certification OR RHIA certification is required. The Coder shall have a minimum of 2 years coding experience of ambulatory surgical cases covering a variety of specialties to include ophthalmology, ENT, plastics, oromaxillofacial, surgical oncology, orthopedic, dermatology and urology. The Coder shall have a thorough knowledge of current coding and classification systems. In addition, the Coder shall be quick to lean and adaptable to change and must possess sufficient clinical knowledge to allow for accurate and resourceful coding of the medical record.
1. Adheres to policies and procedures pertaining to confidentiality of information contained in the medical record.
2. Codes all medical records accurately using ICD-10-CM and CPT classification systems as appropriate according to established Hospital policy.
3. Uses Meditech and 3M to aid in assigning appropriate diagnosis and procedure codes
4. Understands coding rules in relation to requirements by various agencies
5. Maintains current knowledge concerning coding and reimbursement guidelines by reviewing approved coding publications, etc
6. Makes judgments regarding incomplete documentation in the medical record and notifies the HIM Manager for completion to assure accurate coding
7. Maintains a coding accuracy of 95% each month
