HIM Coder

POSITION TITLE: Health Information Coder - Certified

Department: Health Information Management

Reports to: Health Information Director

Date: June 18, 2013, September 15, 2022

Mission of Department: To maintain quality healthcare records and to meet or exceed our customer expectations.

Purpose of Position: The Hospital Inpatient/Outpatient Coder reviews clinical documentation and diagnostic results as appropriate to extract data and apply appropriate codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the Health Information Manager, inpatient and outpatient conditions and procedures are accurately coded as documented in the ICD-10-CM Official Guidelines for Coding and Reporting published annually by the Centers for Medicare and Medicaid Serves (CMS) and the National Center for Health Statistics (NCHS), as well as by adherence to the coding policies and procedures established within this organization's Health Information Management (HIM) department, and any applicable state laws. Adherence to the healthcare organization's information privacy practices is also required.

The Hospital Inpatient/Outpatient Coder resolves error reports associated with the billing process, identifies and reports error patterns, and, when necessary, assists in design and implementation of workflow changes to reduce billing errors.

Essential Functions:

• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for both inpatient and outpatient encounters.
• Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures.
• Utilizes technical coding principles and MS-DRG reimbursement expertise to assign appropriate ICD-10-CM diagnoses and procedures on inpatient encounters.
• Utilizes technical coding principles and APC reimbursement expertise to assign appropriate ICD-10-CM diagnoses and CPT/HCPCS procedures on outpatient encounters.
• Assigns present on admission (POA) value for inpatient diagnoses.
• Identifies chargeable items for emergency department, specialty clinic visits, medical outpatient and series accounts and verifies appropriate charges are present prior to abstracting outpatient encounters.
• Extracts required information from source documentation and enters into encoder and abstracting system.
• Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge, as well as the admit type and admit source.
• Reviews daily system-generated error reports to correct or complete errors identified through the bill scrubbing process.
• Assists in implementing solutions to reduce back-end billing errors.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Assists with assembling the content of medical records of patients treated in the hospital setting into established order for permanent filing.
• Assists with review of medical records of patients treated in the hospital setting for completeness per established documentation requirements.
• Notes deficiencies to be completed by physicians or other professional staff.
• Assists with tracking of records throughout the completion process.
• Assigns appropriate codes for reimbursement purposes and to reflect the severity of services.
• Abstracts all patient encounters using the appropriate software application.
• Assists with monitoring the uncoded admissions report to ensure all records are received in the department and processed timely.
• Assists with any other duties as the need arises.
• Assists with chart review requirements to insure accuracy and completeness.

The preceding functions have been provided as examples of the types of work performed by employees assigned in this job classification. Management reserves the right to add, modify, change or rescind work assignments and to make reseasonable accommodations as needed.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skills and /or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education, Qualifications, Experience:

• Two years direct coding experience and completion of a certified coding program, specifically RHIT, CPC, CCS, or CCA through AHIMA or COC-H through AAPC, or an Associate's Degree in Health Information Technology.
• Completion of anatomy and physiology coursework with basic knowledge of anatomy & physiology, pharmacology and fundamental disease process.
• Successful passing of AHIMA's CCA or CCS or AAPC exam or COC exam.
• High school graduate.

Personal Characteristics: Initiative, tolerance, adaptability, motivated, positive regard for others, objectivity, self-assessment, analytical, flexible, able to interrelate with others, willing to learn, assumes responsibility, does not wait to be told what to do and how to do it, inquisitive, accepts individual challenges, adaptability, listens effectively, gives clear directions, good judgment and decision-making skills, ability to summarize, probe and clarify.

Knowledge, Skills, and Abilities:

• Proficient in word processing and spreadsheets.
• Above average communication skills and the ability to relate effectively to the public and health care professionals.
• Knowledge of coding rules and regulations.
• Attention to detail is vital.
• Meticulous with paperwork and proofreading.
• Able to handle repetitive work, work fast, work accurately under pressure, and motivated to work without close supervision.
• Ability to read and understand medical terminology, to read and understand written reports, and to abstract pertinent information from records.
• Clerical perception is required to spot pertinent details in material.

Expectation of Service: This is a non-exempt 40 hour per week position. Regular and punctual attendance is required.

Physical Requirements: This position requires continual sitting and typing at a computer terminal, some walking, bending, stooping, and lifting of up to 25 pounds.

Equipment:

• computer/printer
• copy machine
• fax machine

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