Medical Coder

Medical Coder

JOB TITLE:           Medical Coder

DEPARTMENT:  HIM

REPORTS TO:     Medical Records Supervisor

POSITION SUMMARY:

• Is accountable for the delivery of consistently high quality effective and efficient entry of information into the computer system.
• Functions under the supervision of Health Information Management.
• Ensures appropriate organizational practices are in use.
• Promotes good public relations through contacts with patients, practitioners, visitors, employees, peers and the public at large.
• Maintains confidentiality of patient information.

POSITION RESPONSIBILITIES

ESSENTIAL FUNCTIONS:

• Analyzes medical record documentation to determine the appropriate coding and sequencing of principal diagnosis, complications, co-morbidities and operative procedures.
• Responsible for all coding and abstracting of observation, inpatient and swing bed accounts.
• Assists in monitoring and maintaining the unbilled financial report on a regular basis.
• General knowledge of outpatient, inpatient, emergency department records and reference labs, using the 3-M encoder and assigns the appropriate ICD-10 CM, ICD-10 PCS and CPT coding system for diagnostic and procedure codes. Follows Medicare guidelines for coding and billing.
• Checks observation, inpatient and swing bed records for correct charges and makes sure any inaccuracies in charging are corrected before the bill is released.
• Contacts physicians and ancillary departments for clarification of diagnoses, procedures, sequencing and/or documentation when needed.
• Utilizes the EMR software program to locate patient information and assign proper ICD-10 CM and ICD-10 PCS codes. Uses all available references to assure correct assignment of codes.
• Codes consistent with all national recognized standards. Uses Coding Clinic for rules on ICD-10. Uses other standards as designated in department specific coding compliance manual.
• Possess an understanding of the prohibition against unethical and illegal practice of maximizing payment by means that is contradictory to regulatory guidelines.
• Monitors and reworks denials as needed.
• Stays current with ICD-10 and CPT through coding clinics and seminars, as well as changes in the Medicare/Insurance industry.
• Participates in quality improvement activities of Health Information Services and the hospital wide quality improvement program.
• Ability to read and comprehend a large variety of memos, insurance requests, business letters, physician orders, nursing notations, diagnostic department reports and other information contained in patient’s records.
• Answers phone and performs necessary tasks.
• Handles requests for information following required guidelines.
• Abides by changes within the department.
• Assists in implementing department specific goals and objectives in keeping with organizational goals and objectives. 
• Assists in maintaining adequate and effective communication between the Medical Record Department and ancillary departments for problem solving. 
• Interacts with others (on the phone or in person) in a positive, professional and appropriate manner.
• Works cooperatively with others.  Has respect for and an understanding of the contributions of all team members.
• Attends required meetings.  
• Protects patient confidentiality by promoting appropriate staff communication practices.   
• Performs other related duties as assigned or requested.
• Daily tracking of own medical necessities and denials.

POSITION QUALIFICATIONS

MINIMUM EDUCATION

High School Graduate or GED.  Education in anatomy, physiology and medical terminology helpful.

PREFERRED EDUCATION

Associate Degree preferred, AAPC/AHIMA coding certification required. Education in anatomy, physiology and medical terminology preferred.

MINIMUM EXPERIENCE

0 – 2 years ICD-10 and CPT coding experience. 

PREFERRED EXPERIENCE

2-4 years ICD-10 and CPT coding. Experience with injection/infusion coding preferred

Qualifications