Medical Office Coder

Summary

The Medical Office Coder will have frequent interactions with internal and external clients including but not limited to Physician and Non-physician Surgical Providers. Responsibilities include primary diagnosis and procedural coding for the designated major surgical specialty areas (Orthopedics) and other major procedural areas. The Medical Office Coder focuses their work on the detailed physician office encounter abstraction as well as being an immediate liaison to documentation improvement and optimization of physician coding practices for compliance and revenue purposes for the providers in these areas. Daily abstraction coding is defined as identification of codes based solely on the source documentation for CPT and ICD-10-CM respectively.

Responsibilities

• Primarily process daily encounters submitted by the provider. Review the complex (problematic coding that needs research and reference checking) medical records and accurately codes the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions. Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM and CPT coding guidelines to non-facility diagnoses and procedures.
• Communicate with administrators and ancillary services personnel for needed documentation for accurate coding. Provide real-time feedback to providers as it pertains to proper coding and clinical documentation of services performed. Engage in provider/ department contact and education as the primary liaison for clarification of documentation and coding for defined daily office encounters including documentation deficiencies.
• Perform other related duties incidental to the work described herein.
• Adheres to and supports the objectives, policies and procedures of Illinois Bone and Joint Institute and its handbook.
• Supports the development and implementation of improvement initiatives as it relates to the department goals.
• Maintains confidentiality of patient information according to HIPAA guidelines.

Education:

• High School Diploma or equivalent required.
• Associates degree in health information or equivalent is preferred.

Degrees, Licensure, and/or Certification:

Certified Coding Specialist (CCS-P), Certified Professional Coder (CPC), Certified Coding Associate (CCA), or Certified Outpatient Coder (COC) is required.

Registered Health Information Technician (RHIT) is a plus.

Experience/Skills:

• A minimum of two (2) years’ experience coding and charge processing in a non-facility (physician or medical group in multi-specialty surgical practices) setting required.
• Must be able to code charges based on reading and interpreting medical documentation
• Extensive knowledge of coding non-facility procedures, applicable modifiers in multi-specialty setting
• Understands and applies appropriate Center Medicare Services (CMS) guidelines to coding.
• Advanced ICD-10-CM & CPT coding conventions.
• Understanding of Anatomy & Physiology and Medical Terminology
• EMR experience required; Epic is a plus
• Encoder experience required; Codify is a plus
• Effective written and verbal communication skills