Outpatient Coder 2

Job Description

Essential Duties & Responsibilities including but not limited to:

• Review the complete electronic and scanned medical record of discharged patients. Assigns ICD-10-CM, CPT/HCPC, and Modifiers from documentation in the medical record.
• Abstracts coded data and patient information into the coding abstracting system in use by BILH (examples of information includes attending physician, surgeon, dates of surgery, disposition, discharge date, and infant birth weight).
• Applies ICD-10-CM and CPT Official Guidelines for Coding and Reporting, AHA Coding Clinic Advice, and facility specific guidelines when coding outpatient records.
• Sequences the assigned codes using 3M software, exercises all principles of assigning and sequencing ICD-10-CM and CPT/HCPC codes for comprehensive coding and appropriate APC assignment.
• Participates in training programs, including educational sessions for ICD-10-CM and CPT/HCPC coding guidelines and updates.
• Follows hospital specific guidelines to identify and facilitate prompt resolution of documentation, abstracting and/or other account problems.

Qualifications

• Hospital Coding: Minimum of an Associate degree in Health Information Management or Completion of an AHIMA or AAPC Coding Certification program, required. RHIA, RHIT, or CCS from AHIMA or a COC from AAPC, required.
• Professional Coding: High School Diploma or equivalent, plus additional specialized training associated with the attainment of a recognized Coding Certificate. CPC (Certified Professional Coder through the American Academy of Professional Coders) or CCS-P (Certified Coding Specialist Physician based through the American Health Information Management Association), preferred.
• Minimum 2 years of ICD-10-CM, CPT/HCPC Outpatient coding assignment, required.
• Microsoft Office applications.
• Interventional Radiology, Cardiac Cath, Injection and Infusion, Observation, and Ambulatory Surgery coding experience, preferred.
• Computer skills.

Skills, Knowledge & Abilities

• Medical terminology.
• Proficient in Microsoft Office Excel, Word, and PowerPoint applications.
• Knowledge and understanding of current ICD-10-CM and CPT Official Guidelines for Coding and Reporting.
• Knowledge of medical records content and management.
• Working knowledge of the EMR either through experience or education, including experience working with structured data and database management.
• Strong written communication skills.
• Knowledge of laws and regulations about health information and patient confidentiality.

Business Relationships

• Coding Director - Day to day direction, scheduling and support.
• Medical Staff - Support, education and training.
• Coding colleagues - Process improvement, knowledge sharing, quality of work, productivity and training and education.
• External facilities - Work with hospitals, provider practices and vendors on requests related to Coding and Validation.