Job Description Summary
The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements.
Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD‑10‑CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines.
Support the reporting of healthcare data elements (e.g., diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g., reimbursement, value based purchasing initiatives, and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines.
Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements.
Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
Utilize official coding rules and guidelines to apply the most accurate coding to represent patient services on the hospital claim.
Comply with comprehensive internal coding policies and procedures that are consistent with requirements.
Attend coding meetings and roundtable sessions.
Participate in daily huddles and LEAN problem‑solving activities.
Work with focus and no distractions while working and participating in meetings.
Ensure camera is on while attending Teams calls.
Assist with organizing the shared drive for the medical coding department.
Perform other duties as assigned by manager.
Albany Med Health System is an equal opportunity employer.
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