Facility Medical Coder -Outpatient

Job Description Summary

Under general supervision and according to established procedures, assigns diagnostic codes as well as EM leveling for facility to medical record information. The Coder I is responsible for accurate and timely assignment of codes to diagnoses and procedures for all Facility Outpatient cases including but not limited to same day surgery, Emergency Room and Observations. Using established department policies and procedures in conjunction with the current version of ICD-CM Classification for Hospitals, the Coder I will assign the most appropriate codes for OPPS. Coder I will utilize their experience and knowledge to determine the correct first list diagnosis, , secondary diagnoses, CPT procedure codes and secondary procedure codes. The Coder I is empowered at South Shore Hospital to query providers when documentation requires clarification and he/she proactively works with HIM and medical leadership to address concerning documentation trends. The Coder I works with direct support from and under the direction of the HIM Coding Manager to make certain their skills and knowledge remain in peak condition. As a vital member of our respected team the Coder I will work collaboratively with other areas of the Health Information Management department and the Clinical Documentation Integrity unit to advance the profession and reinforce the valuable contributions coders make to the care delivery system.

Job Description

ESSENTIAL FUNCTIONS

1 - Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures.  Assigns proper ICD-CM and CPT diagnostic and operative procedure codes to charts and related records by reference to designated coding manuals and other reference material.

   a - Codes ____ (# determined according to type of record coded) records per hour, consistently with 95% accuracy.

   b - Maintains within five (5) days after discharge coding requirements.

2 - Applies Uniform Hospital Discharge Data Set definitions to select the principal diagnosis, principal procedure and other diagnoses and procedures which require coding, as well as other data items required to maintain the Hospital data base.

   a - Verifies that coded information is entered into the databases without any errors within five (5) days of patient discharge.

3 - Applies sequencing guidelines to coded data according to official coding rules.

4 - Assesses the adequacy of medical record documentation to ensure that it supports the principal diagnosis, principal procedure, complications and comorbid conditions assigned codes.  Consults with the appropriate physician and/or appropriate parties to clarify medical record information.

   a - Identifies any documentation inadequacies with physician and/or appropriate parties and clarifies medical record information with courtesy and tact.

5 - Answers physicians/clinician questions regarding coding principles, DRG assignment and Prospective Payment System.  Assists Finance, Data Processing and other departments with coding/DRG issues.

   a - Assists physicians and ancillary departments with coding questions with timeliness, courtesy and tact.

6 - Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature and so forth.

   a - Utilizes professional affiliations, etc., in order to maintain current in professional developments.

   b - Attends all pertinent coding seminars.

   c - Maintains updated coding books.

JOB REQUIREMENTS

Minimum Education - Preferred

Equivalent to an Associate's Degree in Medical Information Technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD-10-CM coding and prospective payment) preferred.

Minimum Work Experience

Six to twelve (6–12) months of experience preferred.

Required Certifications -

CCS or COC - Certified Coding Specialist OR Certified Outpatient Coder

Required additional Knowledge and Abilities

Eligible for designation as a RHIT, RHIA preferred.