Hospital - Outpatient Coder

Job Description

The Outpatient Coder is responsible for conducting the quality review of outpatient medical records, assuring coding compliance with federal regulations, and maintaining up-to-date coding guidelines and coding-related policy changes. Reviews, interprets, and assigns diagnostic and procedural codes based on medical record documentation according to correct coding principles. Preserves the confidential nature of the information. Supports and maintains UT Health San Antonio policies, protocols, and values. Works under the general supervision of the Coding Operations Manager in a hospital setting.

Responsibilities

• Interacts and communicates effectively with members of the coding team, CDI, quality, and other external departments.
• Participates and provides feedback during department meetings and education services.
• Share knowledge with the coding team and appropriate external departments.
• Assists department team members in resolving coding challenges.
• Assists with mentoring or training new coders on workflows and applications.
• Examines and interprets documentation from medical records and completes accurate ICD-10-CM and CPT code assignment of diagnoses and procedures using an electronic encoder application and electronic medical record.
• Abstracts administrative and clinical data from the electronic medical record for secondary use, primarily responsible for coding emergency, ancillary, recurring, and HOPD patient encounters.
• Enters facility coding charges when necessary.
• Reviews and resolves coding edits
• Initiates queries with providers to obtain or clarify documentation as appropriate.
• Works from a coding queue, completing and re-assigning accounts correctly.
• Assists in coding reviews and second level reviews as needed.
• Adheres to strict federal coding rules in selecting codes that appropriately reflect conditions and treatment.
• Balances need for accuracy against timely completion for billing deadlines.
• Supports meeting organizational unbilled goals for Accounts Receivable with uncoded accounts.
• Performs all aspects of daily work in a manner that contributes to and ensures an environment of strict confidentiality.
• Performs all other duties as assigned.
  
  

Qualifications

EDUCATION:

High school diploma or equivalent required

Experience

Some experience in medical records abstraction and coding in an acute care setting is required.