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+ Position Summary

+ Under limited supervision, reviews all documentation in the patient health record to accurately select the appropriate ICD-10-CM / PCS codes and CPT codes. The coder ensures all actions taken in carrying out responsibilities reflect and support patient centered care.

+ Position Responsibilities

+ Unit Specific Position Responsibilities

+ Extensive review of all inpatient and outpatient health records in relation to assignment of appropriate codes that represent classification of diseases and procedures for both DRG and non-DRG based payers and data collection.

+ Collaborates and communicates with the clinical documentation specialists to ensure appropriateness of documentation. Reviews clinical documentation specialist information using Coding and CDI applications.

+ Identifies deficiencies in physician documentation and communicates using the physician query process to request clarifications as needed. Reviews records for accuracy and completeness of required contents and notifies HIM identified staff when critical errors are located. Follows specific processes when corrections are needed.

+ Verifies codes selected are supported by both documentation in the medical record and nationally recognized coding guidelines.

+ Understands and is a resource regarding coding guidelines and rules.

+ Reviews coding and billing edits for accurate modifier assignment when appropriate.

+ Understands and follows the AHIMA Standards of Ethical Coding as well as the MGMC HIM Coding and Ethics Policy.

+ Accurately selects CPT based on physician documentation for posting of required charges.

+ Attends coding education as scheduled and provided by the HIM department. Obtains continuing education requirements.

+ Remote workers follow departmental policies specific to working off-site.

+ Meets productivity and quality guidelines for the assigned job role.

+ Knows and follows work schedule, requests PTO within time requirements while ensuring that staff coverage is adequate. Responsible for keeping time and attendance application up to date and accurate.

+ Qualifications, Knowledge & Experience

+ Required Qualifications (Including any licensure, certification, education):

+ Currently held coding credential for RHIA, RHIT, CCS, or CPC.

+ Minimum Inpatient and Outpatient coding experience of 5years (ICD10, CM/PCS; CPT; HCPCS).

+ Knowledge of medical diagnoses and operative procedures, laboratory and radiology procedures; of patient chart format, hospital admission procedures, patient care, in-patient and outpatient services, DRG and non-DRG reimbursement system and implications, CCI and LCD/NCD requirements.

+ Organizational Requirements:

+ Maintain stroke education per regulatory requirements.

+ Preferred Qualifications:

+ None Specified

+ Required Knowledge, Skills & Experience:

+ Ability to evaluate appropriateness of diagnoses and procedures; to read and understand documentation, to select and assign codes using various coding systems, to abstract using various abstract programs.

+ Ability to understand and use encoder application, with various references and resources also available.

+ Ability to work closely with other departments regarding clinical documentation needs.

+ Ability to adapt to changes and the initiative to keep abreast of changes in the medical field.

+ Preferred Knowledge, Skills & Experience:

+ None Specified