Coder (Business Office)

Primary Purpose: To provide customer service to both the internal and external customers of the Health Information Management Department in a timely fashion. Review all outpatient encounters, selecting appropriate ICD-10-CM* and ICD-10-PCS* codes to reflect the diagnoses and course of treatment.              

Formal Policy-Setting Responsibilities: No formal responsibility.  The policies associated with the job’s purpose and essential responsibilities are set by others.                                           

Routine Decision Making: Selects ICD-10 CM* diagnostic codes and CPT-4 procedure codes for outpatient procedures, and ICD-10-PCS codes for inpatient procedures to obtain appropriate reimbursement. Coders also verify the correct charges are on the chart in accordance to physicians’ orders.                                       

Formal Supervisory Responsibility: No formal supervisory responsibility.                                               

Unusual Working Conditions: None.                                       

ESSENTIAL RESPONSIBILITIES AND TASKS

Codes records using ICD10-CM* coding guidelines and ICD-10-PCS procedure coding guidelines.  Trucode Encoder. (85% of time)                                                    

• Determines appropriate ICD10-CM and ICD-10-PCS procedure codes for inpatient procedures and CPT-4 treatment codes for outpatient procedures, utilizing the Trucode encoder for all code selections on outpatient charts assigned.                                                
• Abstracts completed records entering correct information in the required abstract field, with minimal errors, verifying other pre-entered fields bypassed.
• Making sure that codes are assigned correctly and sequenced appropriately as per government and insurance regulations.
• Complying with medical coding guidelines and policies.
• Following all medical necessity edits by communicating with departments on charging, documentation and sending physician queries. 
• Coders may be involved in audit processes as needed by Health Information Management (HIM)/Coding Coordinator.

Answers phone calls in accordance with departmental standards. (5% of time)

• Answers both internal and external phone calls utilizing proper phone etiquette, within three rings, two rings preferred.                                                           
• Refers unresolved patient/customer issues to the Health Information Management Coordinator. 
• Forwards calls appropriately 100% of the time.

Prepares records for scanning as necessary (5% of time).                                                             

• Prints separator sheets for encounters coded.                                                    
• Places separator sheet appropriately with in encounter. 

Performs other duties as requested by HIM/Coding Coordinator. (5%of time)

• Meet productivity and quality standards.
• Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results. 

ESSENTIAL PHYSICAL REQUIREMENTS 

• Sedentary Work: Lifting 10# maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools.  Jobs are sedentary; if walking and standing are required only occasionally.                                                        

PHYSICAL DEMANDS 

• Lifting:  Raising or lowering an object from one level to another (includes upward pulling).             
• Carrying:  Transporting an object, usually holding it in hands or arms or on the shoulders.               
• Pushing:  Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions).                                                      
• Pulling:  Exerting force upon an object so that the object moves toward the force (includes jerking).        
• Hearing:  Ability to determine audible communication.                                                   
• Handling:  Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved).                                                            
• Fingering:  Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling).                                                                                                 
• Repetitive Motions:  Substantial movements (motions) of the wrist, hands, and/or fingers.            
• Speaking: Expressing or exchanging ideas by means of the spoken word.  Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.          
• Acuity, near - clarity of vision at 20 inches or less.              

WORKING CONDITIONS 

• Inside:  Worker spends approximately 95% or more of time inside.                                                            

Qualifications

Education and Certification/ Registration Required for the Position: Coding Certification required. CPC, CPC-H, CCS, and/or RHIT

Required Knowledge: Extensive knowledge of medical terminology, anatomy and physiology.  Working knowledge of ICD10-CM*.                                        

Preferred Skills and Ability: Proficiency in computer skills. Good communication skills with some experience working with physicians. Ability to maintain a high level of integrity and confidentiality of medical information. Strict attention to detail.