Overview Job Description - Coder II (7454-1498)
Wythe County Community Hospital
Description
POSITION SUMMARY: Under the direction of the Health Information Management Director, the coder II accurately determines ICD-10-CM diagnosis codes, ICD-10-CM, CPT and HCPCS procedure codes for all patient types including inpatient, observation, surgical day care, Emergency Department (ED) outpatient and recurring patients.
Responsibilities Abstract pertinent information from patient records within various inpatient and outpatient types. Assign ICD-10-CM/ ICD-10-PCS codes or HCPCS codes, creating ambulatory payment classification (APC) or diagnosis related group (DRG).
Monitor and manage the discharged not final billed (DNFB) accounts within assigned patient types daily to meet financial goals and expectations.
Meet coding productivity standards and accuracy rate determined by company policy. (See Coding Productivity and Quality Standards.)
Query clinical staff to achieve accuracy in coding.
Closely communicate with the clinical documentation specialist and advise on coding rules and guidelines; support the clinical documentation improvement program.
Educate, train and communicate with medical staff regarding accurate documentation for coding purposes.
Keep abreast of coding guidelines and reimbursement reporting requirements. Bring identified concerns to supervisor or department manager for resolution. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding guidelines.
Abstract data and reports to the Virginia Trauma Registry.
Participate in the appeals process for coding denials. Initiate and respond to requests for billing to support medical necessity, appropriateness of code assignment, payer requirements, and other activities to support the billing function.
Answer telephone and respond to requests in a professional, timely manner.
Maintain professional credentials through ongoing coding education as well as company requirements for annual continuing education.
Contribute to quality improvement activities of the department and the organization, including participation in internal department and corporate audits.
Participate in other department or organizational activities as requested.
Knowledge, Skills and Abilities Effective oral and written communication skills
Demonstrated competence with personal computers, networks, and Microsoft Office
Experience with various coding abstracting and coding systems
Ability to work independently or as a team member to accomplish tasks or projects
Ability to prioritize work assignments during periods of stress
Ability to sit for long periods of time
Corrected visual acuity for long periods of reviewing/reading medical records and viewing a computer monitor
Knowledge and skills to correctly assign principal diagnosis for inpatients and reason for visit/first listed diagnosis for outpatient encounters; correctly assign additional diagnoses based on coding rules and guidelines
Critical thinking, time management, and organizational skills
Age Groups Served Age Specific
Definition
Yes
No
Birth to One Year • Infant
2 – 3 Years • Toddler
4 - 5 Years • Pre-Schooler
6 – 11 years • School Age
12 - 17 years • Adolescent
18 – 30 years
31 – 64 years • Adult
65+ • Geriatric
No responsibility to treat or care for patients
Working Conditions Exposure to: None, Some, Frequent
Typical exposure indicators are listed below.
Toxic/caustic chemicals – X
Dust/fumes/gases/helicopter – X
Moving mechanical parts – X
Blood or Body Fluids – X
Communicable Diseases – X
Potential electrical shock – X
X-ray electromagnetic energy – X
Needles or sharp objects – X
Frequent repetitive motions – X
Use/viewing of Computer monitor – X
Unprotected heights – X
Physically or verbally abusive patients – X
Hazards in patients’ homes – X
Extreme heat or cold – X
50% of time spent traveling – exposure
Exposure to high pitched noises – X
Physical Demands / Lifting Requirements Sedentary Work : Lifting 10 lbs. maximum and occasionally lifting and/or carrying articles.
( ) Light Work : Lifting 2 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs.
( ) Medium Work : Lifting 50 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs.
( ) Heavy Work : Lifting 100 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 50 lbs.
( ) Very Heavy Work : Lifting objects in excess of 100 lbs. with frequent lifting and/or carrying of objects weighing 50 lbs. or more.
( ) Ability to lift, push and pull with assistance of mechanical device or co-worker
Activity
Some
Frequent
Repeated Bending, Stooping, Kneeling, Crouching
X
Working in confined area
X
Ability to distinguish Colors
X
Standing/Walking > 25%
X
Standing/Walking > 50%
Standing/Walking > 75%
X
Multi-tasking, ability to work with frequent interruptions
X
Hand/eye coordination
X
Use of Computer >75%
X
Critical Thinking Skills
X
Reaching above shoulder level
X
Climbing on Ladder
Operating Motor Vehicle or motorized equipment
Position Requirements Post high school specialty or vocational training with a specialization in courses in medical terminology, anatomy and physiology, basic disease process, ICD-10-CM and CPT-4 or equivalent competency
Successful completion of a coding certificate program in a program with American Health Information Management Association approval status
Minimum of 3 years of acute hospital coding and abstracting experience required
Experience and/or education in ICD-10 CM/ ICD-10 Procedural Coding System (PCS) coding required
Certification or licensure as a: CCS or must obtain CCS credential within 2 years (required)
RHIA or
Certified Professional Coder-Hospital (CPC-H)
And must obtain the CCS credential within 2 years of employment or have equivalent acute care coding and abstracting experience.
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