Outpatient Coder

1. Codes outpatient charts and/or professional charts and abstracts all required data from records according to established procedures; including medical necessity for Medicare charts.
2. Uses ICD-10 CM/PCS/CPT-4/chargemaster to code all diagnoses, operative procedures and physician procedures performed for outpatient procedures.
3. Verifies/changes levels of care provided according to level of care guidelines.
4. Captures all missing records and documentation, i.e. IV start/stop times, etc.
5. Interacts with physicians and physician's offices regarding diagnoses or coding questions.
6. Performs other work as needed to help within the department.
7. Keeps current with coding practices and skills through in-services, seminars, workshops and current literature to increase coding knowledge.
8. Reviews the entire medical record for identification of all documented conditions, diagnoses and procedures.
9. Demonstrates the ability to read physicians handwriting and interpret diagnostic and therapeutic information.
10. Attends and participates in departmental meetings.

Must be a high school graduate or equivalent. College education with an RHIT, RHIA, CCA, CCS, CPC, COC, CMC or CIC credentialed, or equivalent experience required. Must have comprehensive knowledge of ICD-10, CPT and HCPCS codes. Two (2) years coding preferred. Experience with computerized record abstraction systems preferred.

Assumes responsibility for coding and abstraction of all records using ICD-10CM/PCS and CPT classification systems. Reviews records to ensure optimum reimbursement based on medical record documentation. Identifies health and safety concerns and unsafe work practices within the workplace. Is involved in developing safe work practices and is held accountable for the day to day efforts of ensuring a safe workplace by following safe work practices.