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.
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.
