Coder II

Cibola General Hospital, Grants, New Mexico

About the role

Accurate assignment of ICD-10-CM/PCS, CPT-4 codes, HCPCS and Modifiers to the highest level of specificity as supported by documentation in the medical record in compliance with governmental regulations and hospital policies. Review of the quality of data and documentation and facilitate improvement. Responsible for reviewing medical records/assigned charges as necessary for accuracy.

Responsibilities

• Apply inpatient, emergency room, observation, day surgery and clinic/outpatient coding guidelines depending upon the patient type being coded. Fill in when other coders are out of office.
• Code RFV (Reason for visit), which are the patient’s own words on why they are presenting for services.
• Code as the principal diagnosis “The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care,” adhering to Cibola General Hospital’s Coding, Abstracting, Data Retrieval Policy and Procedure and AHIMA’s Standards of Ethical Coding.
• Code secondary diagnosis(es) and operative procedure(s) in the medical record for clarification, agreement, co-morbidities/complications, and additional information.
• Identify reasons that an account cannot be coded/abstracted and place cases not final coded on hold with the appropriate hold reason. Notify HIM Director of reasons/issues with uncoded accounts.
• Query the attending physician utilizing the Cerner message center for further clarification or help as needed for greater specificity, clarification, or correct sequencing of codes utilizing a compliant query process.
• Enter final coding and abstracting information utilizing 3M accessed through the Cerner electronic medical record (EMR).
• Assist in training new or contract coders when the Lead Coder is unavailable.
• Maintain a 95% coding accuracy rate or higher.
• Code off of the assigned coding queue(s) in Cerner but run a Discharged Not Final Coded (DNFC) list daily and as necessary to identify all accounts not coded/abstracted.
• Code and abstract both discharged inpatient and outpatient charts within 3 days of discharge. Notify HIM Director of issues affecting the ability to code discharged charts.
• Assist HIM and PFS Directors in addressing coding errors on denied claims.
• Help maintain hospital charge master (request codes that do not exist in charge master that need to be added).
• Provide support services to hospital administration on a variety of special projects related to improving operational and financial performance when requested.
• Perform Performance Improvement projects as needed and understand the performance improvement process at Cibola General Hospital.

Requirements

• Current RHIT, CCS, CCS-P, or CPC certification required.
• Extensive knowledge of medical terminology, anatomy and physiology, and disease processes.
• Minimum of 3 years of inpatient and outpatient coding experience.
• Knowledge of ICD-10-CM/CPT/HCPCS, assigning modifiers, and prospective payment systems.
• Strong computer skills with knowledge of Microsoft Outlook, Word, Excel, and 3M.
• Ability to work with detail.

Physical Requirements

• Occasionally: Walking, Stooping, Bending, Kneeling, Crouching, Twisting, Stretching/Reaching, Pushing/Pulling, Lifting/Carrying up to 20 lbs.
• Frequently: Sitting, Standing, Hand-finger dexterity, Lifting/Carrying up to 30 lbs.
• Constantly: Hearing, Speaking, Seeing (colors, brightness, details).
• Exposure: Dust, fumes, noise; limited potential exposure to blood borne pathogens, chemicals/hazardous materials, and air contaminants (including tobacco smoke) in a healthcare facility.