What are the responsibilities and job description for the Coder II position at The County of Santa Clara?
Description
Coder II incumbents work under general supervision performing moderately-complex coding and abstracting of assigned work tasks that may include but are not limited to outpatient, inpatient, or specific medical-service medical records. For training purposes, Coder II incumbents may work with moderately complex inpatient records. Coders at all levels must perform work in accordance with official Federal and State coding guidelines, as well as the coding policies of the Santa Clara Valley Health and Hospital System (SCVHHS).
The list established from this recruitment will be used for all vacancies throughout the Santa Clara County Health System. This may include full time, part time, and extra help positions. If you are interested in these opportunities please fill out the appropriate questions.
Please note: All applicants are required to attach proof of a valid medical coding certificate.
Typical Tasks
(The following list includes examples of tasks that may be assigned to a Coder II position, depending on the area of assignment. No single position will be assigned all tasks listed; nor is the list exhaustive.)
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Reviews, abstracts, and codes medical-record data using coding systems such as ICD-9-CM, CPT-4, and HCPCS or subsequent adaptations;
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May perform coding review or audit of provider charges submitted electronically, charge ticket, or electronic file;
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Provides CPT and ICD-9 codes to unit and other staff when required;
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Records the coding information into the appropriate charge system such as a computer system, paper-charge ticket, and/or electronic file;
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Reviews and abstracts procedural, diagnostic services, and/or facility level of services from the medical record and assigns the appropriate coding;
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Identifies and assigns diagnosis, CPT procedural codes, HCPC codes or facility level of service utilizing the current adaptation of the International Classification of Diseases (ICD-9-4), CPT-4, HCPC or LOS;
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May assign unique coding required by MediCal or other third-party payers when different than the industry standard by CMS;
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Applies knowledge of anatomy, physiology, disease processes, and medical terminology to accurately assign and sequence the procedural coding, diagnoses, or HCPC codes;
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Accurately assigns Medicare Severity Diagnosis Related Group (MSDRG) and Ambulatory Payment Classification (APC) number or other coding classifications;
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(In Diagnostic Imaging Unit) Reviews various radiology reports for appropriate CPT codes and assigns codes accordingly using ICD-9 code set or subsequent adaptation (such as ICD-10) and performs other coding-related duties pertaining to diagnostic imaging;
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Participates in the development of policies and procedures; supports the implementation of departmental policies and procedures;
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Reviews Coder I work for completeness and correctness, and assists in the orientation of new staff to the unit;
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Reviews and resolves charge errors and/or coding discrepancies;
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Follows department policy regarding notification of incomplete or missing information from the patient record;
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Communicate with other departments and providers regarding account clarification and corrections;
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Maintains HIPPA confidentiality, privacy, and security of all patient-related information;
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Maintains harmonious work relationships;
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May be assigned as a Disaster Service Worker, as required;
- Performs other related work as required.
Employment Standards
Sufficient education, training, and experience to demonstrate the ability to perform the above tasks, and possession of the following qualifications, including the knowledge and abilities indicated below:
Training and Experience Note: The knowledge and abilities required to perform these functions are normally acquired through possession of a high school diploma (or GED equivalent), possession of a CCA, CMC (PMI) or CCS or RHIT or RHIA or CPC (AAPC) certification, and two (2) years experience as a medical coder which included coding outpatient and/or inpatient records using ICD-9 diagnosis (or subsequent ICD adaptation), procedures CPT codes, HCPS coding system;
Note: Specific certifications, such as Radiology Certified Coder (RCC)-in lieu of above listed certifications-may be required if specific job duties are such that a particular coding credential is more applicable. Because specific Coder functions and certifications may vary, certifications will be evaluated on a case-by-case basis in order to assess applicability to the Coder II duties assigned as well as the required knowledge and abilities.
Coders are required to maintain their coding competency regarding procedural, diagnosis, HCPC codes and LOS facility charges, a strong understanding of coding, compliance and regulatory payer guidelines, and other guidelines related to coding of medical records. Coders must complete the required Continuing Education Units (CEUs) annually to ensure their respective certifications remain active and in good standing.
Knowledge of:
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Coding guidelines, abstracting, and medical terminology to utilize and assign appropriate coding: current ICD-9-CM and CPT-4, HCPCs or subsequent adaptations;
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Computer encoding software programs, online tools, coding references and websites;
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The principles and practice of accurate and compliant abstracting and coding techniques;
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Comprehensive medical terminology, anatomy and physiology, and disease processes related to medical specialties;
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Components and format of the hard copy and/or electronic version of medical record, including but not limited to laboratory findings, special tests, medications, surgical procedures, therapy services, surgical events, other dictated or hand written process notes and reports, consents, etc;
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English grammar, punctuation, spelling, and general English usage;
- Computerized patient data systems.
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Read and comprehend the elements of a medical chart, medical-record notes, and reports;
Analyze, code, and abstract moderately-complex technical data from medical records covering a wide variety of ancillary/outpatient-and in some cases inpatient - -services;
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Identify missing elements, inferred between procedural and treatment relationships;
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Properly sequence abstracted/coding information from a medical record;
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Read and understand medical record notes and reports and accurately classify all diagnoses and procedures;
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Effectively use the various computer systems necessary to perform job functions;
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Communicate clearly, both orally and in writing, with medical and nursing staff, employees at all levels of the organization, patients, and the public;
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Plan, organize, and prioritize work, and meet deadlines;
- Reason logically, and use sound judgment in the performance of duties.
