Job details

Specialty Coder

The Coder reviews clinical documentation and diagnostic results and applies appropriate ICD-10-CM, and CPT-4 codes. Codes are used for billing, internal and external reporting, research and regulatory compliance activities. Resolves billing related errors and assists with workflow changes and process improvement projects. Meets ongoing productivity and quality standard of 95% accuracy rate or better. Verifies that all ICD-10 codes are correctly captured. Verifies that physician is correctly abstracted. Keeps abreast of coding guideline changes. May identify chargeable items for facility level for given department. May assign codes for diagnoses and treatment for ancillary outpatient encounters. Abides by the standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to all official coding guidelines. Performs other duties as assigned.

Additionally, the Coder III utilizes technical coding principles and APC reimbursement expertise to assign appropriate ICD-10-CM and CPt-4 procedures. Assigns codes for diagnoses, treatment and procedure for multiple specialized departments, including Outpatient ancillary, Emergency Department, and Inpatient and Outpatient Surgery. Determines the correct principal diagnosis, co-morbidities, complications, secondary conditions and surgical procedures. Assigns MS-DRG, Present on Admission (POA) indicators, Hospital Acquired conditions), and accurately abstracts discharge dispositions. Queries physicians per established policy and procedure when documentation is not clear or conflicting.

Education and Experience

High school diploma or equivalent required
Completion of a certified coding program or graduate of a CAHIM accredited HIT program required
Five years of progressive inpatient/E&M coding experience

Certifications Required