Coder IV

Responsibilities

• Sets appropriate admit, & principal and secondary diagnoses and/or procedure codes by reading documentation present in medical record and applying knowledge of correct coding guidelines as appropriate for hospital service and/or patient type while maintaining 95% quality and meeting and maintaining the minimum Coder productivity requirements.
• Assigns Present on Admission PO indicators to all inpatient account diagnoses as required by official coding guidelines.
• Accurately assigns DRG/MSDRG/APR-DRG at the minimum standards of 95%.
• Reviews Diagnosis and CC/MCC for maximum SOI/ROM.
• Knowledge of quality outcomes indicators.
• Work with CDS to improve physician documentation and case mix index.
• Assign Principal Diagnosis accurately at least 95% or better.
• Maintain and appropriately assign HAC codes when appropriate.
• Recognizes when it is necessary to obtain further clarification from physician when documentation is inadequate, ambiguous, or unclear for coding purposes.
• Assists educators and supervisors with reviewing accounts denied by RAC and other governmental payers for appropriate documentation to support original coding.
• In the event of insufficient, missing or conflicting documentation, assigns transaction codes in HBOC system and follows department policy for follow up and physician query.
• Abstracts all data elements necessary to complete UB0 4 and meet hospital-reporting requirements.
• Verifies demographics, corrects account number, charges and service and identifies missing or incorrect forms in each record.
• Identifies problem cases on the DNFB and forwards to appropriate staff for follow up.

Qualifications

• High School or GED: Health Information Management (Required)
• AHIMA - American Health Information Management Association - American Health Information Management Association, CCS - Certified Coding Specialist - American Health Information Management Association

Additional Information

• Work Shift: Day
• Scheduled Weekly Hours: 40
• Department: Hospital Coding