INSTITUTIONAL CODER (Certified Coder)

Description:

OVERVIEW:

Responsible for the thorough and accurate coding of diseases and procedures of each inpatient record using ICD-10-CM/PCS coding manual, TrueCode encoder, in compliance with the Official Coding Guidelines and conventions.

ESSENTIAL JOB DUTIES:

1. Meets the daily coding productivity goals
2. Complies with all HIPAA and confidentiality guidelines
3. Accurately identifies most appropriate Admit Diagnosis, Principal Diagnosis, and Procedure for the DRG, and all secondary diagnoses to accurately reflect all CC/MCC's, POA status, and Severity of Illness and Risk of Mortality. Ensures completion of records by checking for signatures and missing documentation.
4. Accurately abstracts required data elements including, discharge disposition, discharge destination, procedure dates and physician(s), and other designated data.

RESPONSIBILITIES/KNOWLEDGE/SKILLS:

1. Performs initial charge review to determine appropriate ICD and CPT codes to be used to report physician services to third party payers.
2. Interprets progress notes, operative reports, discharge summaries, and charge documents to determine services provided and accurately assign CPT and ICD coding to these services.
3. Enters appropriate data into the Billing System by selecting the appropriate codes, diagnosis, modifiers, and times of start and stop of the case, Anesthesiologist, CRNA, and surgeon information to complete the charge process.
4. Identifies when a physician query is appropriate for further clarification.
5. Responsible for reviewing patient logs and other report of clinical activity to ensure billing is captured for all patients.
6. Monitors and follows up to ensure all services that can be billed are captured and coded for billing.
7. Responsible for ensuring the batch processes for all coded charges.
8. Utilizes batch-logging systems to comply with internal audit standards.
9. Reviews all physician documentation to ensure compliance with third party and regulatory guidelines.
10. Works in conjunction with the Reimbursement staff to answer all inquiries regarding coding and billing for physicians' services.
11. Works in coordination with other members of the billing team, as necessary.
12. Meets and exceeds short- and long-term goals as established for the department.
13. Performs duties and job functions in accordance with the policies and procedures established for the department.
14. Reports to work, meetings, and professional obligations on time.
15. Participates in administrative staff meetings and attends other meetings and seminars.
16. Assists in evaluation of reports, decisions, and results of department in relation to established goals.
17. Recommends new approaches, policies, and procedures to influence continuous improvements in department's efficiency and services performed.
18. Serves as a member of the Revenue Cycle Department. Performs duties necessary to ensure the team's projects/goals are completed.
19. Takes ownership of special projects, research data and follows through with detailed action plans.
20. Actively participates in problem identification and resolution and coordinates resolutions between appropriate parties
21. Perform any other duties that may be necessary for the operation of the corporation and/or hospital

Requirements:

QUALIFICATIONS:

1. Required three to five (3-5) years acute hospital-based coding experience. An equivalent combination of education and experience may be considered.
2. Required Bachelor's Degree or Associate Degree in Health Information Management and/or closely related field Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), or AHIMA Certified Coding Specialist (CCS) credential RHIT or RHIA preferred.
3. HS Diploma required
4. Responsible for thorough knowledge of Meditech (Expanse)

PHYSICAL REQUIREMENTS:

1. Frequent mobility and/or sitting required for extended periods of time
2. Manual dexterity and use of a calculator or computer keyboard.
3. Varied activities including standing, walking, reaching, bending, lifting
4. Occasionally lifts to 25 pounds
5. Requires corrected vision and hearing to normal ranges
6. Requires working under stressful conditions or working irregular hours
7. Exposure to communicable diseases, toxic substances, ionization radiation, medicinal preparations, and other conditions common to a hospital and/or clinic environment