CODER (CERTIFIED)

CODER CERTIFIED

JOB SUMMARY

Responsible for abstracting and coding inpatient and outpatient visits for all Mt. Washington Pediatric Hospital locations. Responsible for working with doctors and clinical staff to improve clinical documentation as needed for accurate coding. Involved in all aspects of planning and implementing coding processes/procedures for the facility.

ESSENTIAL FUNCTIONS OF POSITION

• Accurately abstracts and assigns diagnostic and procedure codes for inpatient and outpatient records.
• For inpatient records, enters final codes into Meditech Expanse System within 72 hours of discharge during normal business hours (Monday – Friday).  
• Final code records for patients transferred to another facility within 96 hours of the transfer during normal business hours (Monday – Friday).
• For outpatient records, accurately abstracts, codes and enters into Meditech within 15 days of the following month in which the patient was discharged for recurring accounts (recurring accounts automatically discharged at the end of each month). 
• All other outpatient accounts (referred) will be coded within 5 days of the service/visit date.
• Assigns admitting diagnosis code (ICD-10-CM) for all inpatients within 48 hours of patient's admission – codes are assigned by end of day Monday for Friday admissions.
• Queries physicians and clinicians as needed to clarify their documentation of the patient's conditions.
• Works to educate them about documenting appropriately for a patient's condition and treatment.
• Is knowledgeable on sequencing final codes to include secondary and tertiary diagnoses (for complications and co-morbidities) so reimbursement is optimized.
• Keeps up to date on coding standards, issues, and practices.
• Researches and keeps abreast of appropriateness of code usage and code changes as needed for payment and for special services and patient groups seen at Mt. Washington.
• Assist with new coding processes and helps implement any changes, as needed.
• Works assigned coding worklist from Meditech Expanse System daily.
• Keeps up on required information to be abstracted from inpatient/outpatient records as required by HSCRC.
• May be asked to assist with the HSCRC data submission deadlines as needed.
• Researches and corrects errors in Meditech as needed. 
• Assist the Coding Coordinator by contacting Admitting and Outpatient Registration Supervisors to correct errors for their respective areas of responsibility. 
• Works with Patient Accounting and Finance to ensure accounts are coded accurately and timely so bills are processed promptly.

POSITION REQUIREMENTS

Educational Requirements: High School Diploma/Equivalent required.

Medical terminology: College coursework required in Health Information Technology/Management and/or completion of ICD-10-CM and CPT coding courses.

Licensure, Certification and Registration:

Work Orientation and Experience:

Knowledge, Skills and Abilities:

Other Requirements Specific to Assigned Area:

Registered Health Information Technician (RHIT) or Registered Health Information Manager (RHIA) or Certified Coding Specialist (CCS).

Minimum of two years’ experience coding inpatient (acute care) records.

Additional experience with outpatient coding preferred.

Knowledge of medical terminology, anatomy & physiology, ICD-10-CM and CPT coding systems.

Computer skills required.

Ability to communicate effectively with the clinical and medical staff.

Ability to work under deadlines.

Ability to organize, prioritize and work independently.

Knowledge of Meditech is a plus.

REPORTING RELATIONSHIPS

Supervision Received: Health Information Management Director

Supervision Exercised: No direct supervisory functions.

INTERPERSONAL RELATIONSHIPS Interfaces with the clinical and medical staff; Patient Accounting; Information Services; Admissions; Outpatient Registration

TOOLS/EQUIPMENT USED

Computer, scanner, photocopier and fax machine.

PHYSICAL ENVIRONMENT/WORKING CONDITIONS

General setting. Occasional stress due to multiple demands and deadlines. Little or no risk of exposure to body fluids, infectious waste or blood-borne diseases. Understands and respects the necessity for privacy and confidentiality in this environment.

This job description identifies the general nature and level of work to be performed. It is not to be considered an exhaustive list of responsibilities, duties or skills required of an incumbent.  

Revised 2/25/20

Revised 12/12/2024