What are the responsibilities and job description for the HIM Coding Specialist position at Carroll County Memorial Hospital?
Position Summary
The HIM Technician will be responsible for reviewing clinical documentation and diagnostic results as appropriate (i.e., to extract data and apply appropriate ICD-10-CM, HCPCS and CPT-4 codes for billing, review and correct billing edits, internal and external reporting, research, and regulatory compliance).
Under the direction of the Health Information Management (HIM) the successful candidate must be able to accurately code conditions and procedures as documented in the ICD-10-CM Official Guidelines for Coding and Reporting.
Essential Functions and Responsibilities
Assigns codes for diagnoses, treatments and procedures according to the appropriate classification system for outpatient encounters to determine the highest level of specificity ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
Reviews physician assigned diagnosis code after thorough review of the medical record and, if necessary, queries physician for additional clarity in a professional manner.
Able to accurately abstract information from the medial records into the abstract system, according to established guidelines.
Enters and validates codes, charges (including surgery and anesthesia) and other edits flagged
Review documentation (and returned accounts) to verify data elements (ie: NDC #, or number of units, etc…)
Uses CCI edit software to check modifier appropriateness and LCD’s/NCD’s for medical necessity.
Communication with other departments (via phone calls, email, or face to face) to recommend coding guidance for charge corrections and patient billing concerns.
Meet and/or exceeds the established coding productivity standards
Meet and/or exceeds the established quality standard of 95% accuracy while meeting and/or exceeding productivity standards
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and American Academy of Professional Coders (AAPC) adheres to official coding guidelines
