Medical Coder

Medical Coder

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 Manager.
• 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.
• General knowledge of outpatient, 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.
• Abstracts designated statistical data and enters the information into the medical record abstracting computer system.
• Checks outpatient records, emergency room department records and reference lab records for correct charges and makes sure any inaccuracies in charging are corrected before the bill is released.
• 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, 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