Job Description Report
Responsible for the coding of diagnoses and procedures on outpatient medical records to ensure complete, consistent, and accurate coding.
Outpatient records refers to outpatient surgical accounts, emergency room, urgent care, ancillary and other outpatient encounters.
[Excludes observation records.
] Provides feedback to providers when incomplete, conflicting, ambiguous, or non-specific documentation is encountered.
Issues queries to the physician to obtain complete and/or specific documentation.
*Will be held accountable to the following Studer Philosophies and Principles:*
* HCAPS Patient Perception
* Hourly Rounding with intention
* Bedside shift Report
* AIDET
* Daily Huddles
*Essential Functions:*
* Accurately and completely codes all outpatient records, to ensure assigned codes conform to current coding conventions, achieving 95% accuracy in code assignment.
Outpatient records include but are not limited to surgical accounts, emergency room visits, urgent care visits, ancillary accounts, occupational medicine, physical therapy, infusion therapy, and other outpatient encounters.
* Performs coding consistent with productivity benchmarks.
* Consults providers for clarifications and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.
* Compiles and generates reports as needed for pricing estimates and other special projects.
* Demonstrates and understanding of other payment methodologies that use clinical data such as Ambulatory Surgery Center (ASC) payment groups, Ambulatory Payment Groups (APG) and Resource Based Relative Value Scale (RBRVS).
* Performs weekly review of uncoded Accounts for missed accounts and codes those noted if necessary documentation is present.
* Demonstrates ability to be flexible and completes all other duties as needed by Coding Data Quality Manager of Director of Health Information Management.
* Other duties as assigned.
Required Skills
*Minimum Education:*
* High school graduate or GED equivalent.
* Associate or Bachelor degree in Health Information Management (or similar program) from an accredited program, preferred.
*Required Licenses:*
* Medical Records and Health Information Technicians.
* CCS, RHIT, RHIA or CPC certification required.
* RHIA/RHIT - new grads considered (must obtain certification within 18 months of hire, CCS or CPC certification within 36 months of hire).
* In lieu of certification or eligibility for RHIA/RHIT certification, candidates with a minimum of 2 years of acute care or ambulatory surgery center coding experience will be considered with the stipulation the CCS or CPC credential must be obtained within 24 months of hire.
RHIT/RHIA - new grads considered (must obtain certification within 18 months of hire/CCS or CPC certification within 36 months of hire).
*Required Skills:*
* Proficient in ICD-10-CM, ICD-10-PCS coding and DRG optimization;experienced with electronic medical record.
* Exceptional communication (verbal and written) and interpersonal communication skills; ability to interact with all levels of the organization effectively; possess high level of organization and ability to work both independently and with members of Medical Staff, Clinical Documentation Improvement Specialists, and other hospital staff.
Required Experience
*Minimum Work Experience:*
* Medical terminology and anatomy and physiology required.
* Minimum of four (4) years' experience in acute care hospital based ICD-10-CM and ICD-10-PCS coding required.
* Experience with CPT-4 coding desirable.
* Working knowledge of AHA coding Clinics and Local Coverage Determination Policies.
Job Type: Full-time
Whatsapp
