Surg/Op Coder

JOB PURPOSE

This position is for an Outpatient Coder with Emergency Dept and Ambulatory Surgery coding experience. The coder will code Surgery, Emergency department, and Ancillary records. Emergency Dept coding includes injection & infusion coding as well as the assignment of the E&M Professional fee. Coder will demonstrate competency by meeting productivity standards and achieving an accuracy rate of 95% on all chart types coded. Will abstract and code every account compliantly, accurately, and completely, to ensure accurate and timely reimbursement and reporting. Verifies, reviews, analyzes, and abstracts medical information; researches missing clinical information; assigns accurate codes; appropriately queries physicians when required; elevates documentation issues to management; ensures valid orders are on the record prior to coding; communicates with Coding Manager daily regarding obstacles that prevent a chart from being coded. Demonstrates proficiency in the coding of these outpatient accounts.

Essential Functions

• Affirms data quality by maintaining a 95% or higher accuracy rate as validated by audit.
• Demonstrates consistent and efficient performance by coding a minimum of 12-15 ED records per hour, 7 outpatient surgery records per hour, 7 observation records per hour, 25-30 outpatient diagnostic accounts per hour.
• Safeguards there is a valid physician order for all outpatient surgery accounts.
• Safeguards proper verbiage on all observation orders.
• Safeguards a valid physician/provider order for all outpatient diagnostic accounts.
• Queries physicians as necessary to clarify missing, ambiguous, incomplete, or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding.
• Absorbs information from the medical record into the abstracting module.
• Posts charges for injection and other procedure coding, as required.
• Notifies Coding Manager and Manager of Revenue Cycle when the surgery order is missing, or the observation order is either missing or does not contain complaint Observation statements.
• Exhibits proficiency with PC and software systems used by the Coding and HIM staff.
• Manages time and workload with understanding of the relationship between coding accuracy, timeliness, and deadlines.
• Completes a minimum of 10 hours of formal education and 10 hours of informal education (reading coding clinics and CPT Assistant), which can be turned to formal by taking the quiz on the back and submitting for credit.
• Performs additional responsibility as directed.

Behavioral Standards

• Exhibit positive customer service behavior in everyday work interactions.
• Demonstrate a courteous and respectful attitude to internal workforce and external customers.
• Communicate accurately and appropriately.
• Handle difficult situations in a discreet and professional manner.

Education/Certification/Licensure

• Must hold an HIM credential (RHIT) or a Coding Certification from AHIMA or the AAPC.
• Coding Certification from AHIMA or the AAPC preferred.

Position Qualifications

• Must have 2 years of coding experience.
• Must pass a company coding test.
• Must possess basic knowledge of HIM principles and department functions.
• Must possess strong knowledge of ICD-10CM, ICD10-PCS and CPT coding rules and conventions.
• Must possess a firm knowledge of medical terminology, anatomy and physiology and disease processes.
• Must have the ability to analyze charts for compliant orders and perform appropriate follow-up for chart deficiencies that impact coding.
• Must have the ability to abstract information from the medical record for indices and statistical reports.
• Must have excellent PC and software utilization skills.
• Must be able to work independently.

Physical Requirements

• To perform this job successfully, an individual must be able to perform each essential job duties satisfactorily.
• The requirements listed are representative of the knowledge, skill, and/or ability required.
• Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Such accommodations must be requested by the employee/applicant to be considered.
• This job requires visual abilities, auditory abilities, must be intact to perform duties.
• Must be able to perform repetitive tasks/motions.