Job Summary: Responsible for accurate coding of outpatient and inpatient professional services, procedures, diagnoses and conditions, working from the appropriate documentation in the medical record. Classification systems include ICD-9-CM, CPT, HCPCS as well as other specialty systems as required by diagnostic category. All work carried out in accordance with the rules, regulations and coding conventions of the American Association of Professional Coders (AAPC) ICD9 (and ICD10 when implemented), AMA CPT and CMS coding guidelines. As needed, Coders may assist and be a resource for data integrity for other employees who need clarification and assistance in coding.
Duties and Responsibilities:
- Review medical records to identify procedures/diagnoses.
- Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM, (and ICD10 when implemented), CPT, Medicare guidelines and other appropriate classification systems.
- Demonstrates knowledge of anatomy, physiology, pharmacology and pathophysiology to interpret general medical classifications for coding discharge data.
- Assigns Codes and codes all diagnostic and operative information from the medical record using ICD-9-CM, ICD-10, CPT and HCPCS coding classification systems and independently quality checks own work.
- Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, and CMS, regional and local policy.
- Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
- Enters patient information into the computerized outpatient medical record databases.
- Ensures timely record availability by meeting established coding and abstracting productivity standards.
- Maintains and complies with policies and procedures for confidentiality of all patient records.
- Acts as an expert resource.
- Performs other related duties as assigned.
Requirements:
- Certification as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
- Minimum one (1) year coding experience within the last three years.
- Completion of classes in medical terminology, anatomy and physiology, ICD-9 and CPT coding conventions, and disease process from an accredited program or equivalent experience. Must maintain current coding credential.
- Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance.
- Ability to understand the clinical content of a health record, including the most complicated records. Must also be able to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses. Will abide by the AAPC or AHIMA coding code of ethics.
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