Coder Noncertified
Accountable for the conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in the sequencing of diagnoses/procedures in accordance with coding guidelines. Ensures that records are coded in an accurate and timely manner.
Duties and Responsibilities:
- Ensures that records are coded within three days of discharge, excluding weekends and holidays.
- Reviews the chart thoroughly to ascertain all diagnoses/procedures.
- Contacts the responsible physician in a professional, tactful manner if the diagnosis is not available on the chart.
- Refers chart to the director, if there is a question regarding the diagnoses/codes.
- Utilizes computerized coding/abstracting equipment.
- Codes all diagnoses/procedures in accordance to ICD-10-CM coding principles and the Coding Manual.
- Meets the productivity standard of assigning codes based on account type.
- Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.
- Maintains 99% rate of information correctly abstracted.
- Assists with education and coding for medical necessity.
- Maintains the number of DRG/coding changes below the 3% quarterly per PRO threshold.
- Reviews coding periodicals within seven (7) days of receipt.
- Notifies the director whenever work is more than 48 hours behind the work deadline.
- Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
- Acts as a resource person to hospital and clinic staff for coding and may provide education regarding coding changes/issues.
- Maintains a good working relationship within the department, other departments, and medical staff.
- Must be familiar with the following manuals: Administration, Health Information Management Department, Fire Safety, Emergency Management and Safety, HIPAA.
- Willing to accept additional assignments.
- Performs performance improvement functions through data collection and documentation review.
Professional Requirements:
- Ensures that appearance and personal conduct are professional at all times.
- Excellent attendance record.
- Wears appropriate clothing for job functions.
- Wears ID badge.
- Works at maintaining a good rapport and a cooperative working relationship with physicians, administration, and staff.
- Represents the organization in a positive and professional manner in the community.
- Maintains patient confidentiality at all times.
- Complies with all organizational policies regarding ethical business practices.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities