CODER II

Department: HIM Coding - UH
FTE: 1.00
Full Time
Shift: Days

Position Summary:
Code inpatient hospital discharges and or specialty services using appropriate ICD and CPT classification systems for the purpose of reimbursement, research and compliance and in accordance with federal regulation. Discharges include all Inpatient, Day Surgery, and Observation accounts. Specialty services include Interventional Radiology, GI Lab, Cardiac Cath lab, and Interventional Pulmonary Procedures. In addition, coding of outpatient encounters through the use of single-path coding, whereby coder codes both facility and professional fee components. Coder must meet department productivity and quality standards. Ensure adherence to hospital and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* RESEARCH - Research compliance with federal regulations according to diagnosis, operation, and procedure using the current version ICD, CPT, and DRG classification systems
* CODE - Abstracts statistical data for discharge records using hospital's abstracting system
* RELATED WORK - Perform related duties and responsibilities as required
* QUERY - Identify and complete appropriate queries to providers when more specific or clarifying documentaion is needed to accurately code IP discharges. Maintian department query statndards and expectations as outlined in department policies and procedures
* CODE - Identify and assign preliminary codes for Inpatient/outpatient records for the purpose of reimbursement, research and compliance with federal regulations according to diagnosis(es), operation(s), and procedure(s) using the current version of ICD, CPT, and DRG classification systems
* CODE - Performs data entry for determining correct Principle Diagnosis and DRG and all secondary diagnosis, and procedure codes
* CODE – Perform coding of single-path encounters, requiring coder to abstract both facility and professional components
* CODE - Resolve medically unlikely edits (MUE), medical necessity (MN) and correct coding initiative (CCI) edits as appropriate

Qualifications

Education:
Essential:
* High School or GED Equivalent
Nonessential:
* Associate Degree
* Vocational or Technical
Education specialization:
Nonessential:
* Related Discipline
* CPT and/or ICD Coding

Experience:
Essential:
1 year directly related experience Medical terminology knowledge

Nonessential:
1 year directly related inpatient coding experience

Credentials:
Essential:
* Department Approved Cert - See Job Description
* Certified Coding Specialist w/in 2 years
Nonessential:
* Registered Health Information Administrator
* Registered Health Information Technician
* Certified Coding Specialist

Credential equivalent experience:
Essential:
* One of the following: Certified Coding Specialist (CCS) Certified Professional Coder (CPC) Certified Coding Specialist-Physician Based (CCS-P) Certified Inpatient Coder Certified Outpatient Coder Certified Risk Adjustment Coder (CRC) Board Certified Home Health Coder (BCHH-C) Radiology Certified Coder (RCC) Certified Interventional Radiology and Cardiovascular Coder (CIRCC) RHIT RHIA

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment
* May perform subordinate tasks in high census/vol