Job Summary: The Junior Coder is responsible for coding medical records, including all diagnoses and operative and diagnostic procedures in patient medical records, using the current International Classification of Diseases (ICD10 CM/PCS), Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedures Coding System (HCPCS) and entering coded information into an automated grouper system. Does related work as required.
Responsibilities: - Using the current HCPCS, ICD10 CM/PCS and CPT coding system, assigns and records an accurate code to all diagnoses, procedures, and operations as documented by the attending physician in the indicated patient's medical record.
- Ensures that all factors necessary for assigning an accurate DRG are present, and that all diagnoses are ranked properly.
- Makes appropriate contacts in order to acquire or clarify necessary information.
- Enters final diagnostic code numbers and narrative descriptions of diagnoses and procedures into an automated grouper system.
- Abstracts information from medical records to compile reports and statistical information.
- Enters data such as diagnosis, treatment, admission and discharge dates, and length of stay on hospital-wide or regional automated database.
- Participates in other medical records functions, as assigned.
- Query appropriate provider as necessary regarding documentation of diagnosis and/or procedure.
- Tracker management: Coding queries and Denials
- Performs other duties as assigned.
Qualifications/Requirements: Experience: The Junior Coder should have either of the following: (a) the CPC, CPC-A, COC, CCS or CCS-P credential; or (b) 1-2 years of experience where the primary function of the position was working with medical records in a health care setting; or (c) satisfactory completion of at least 30 college credits* which included courses in medical terminology and ICD medical records coding or at least six credits* in anatomy and physiology; or (d) satisfactory completion of a college certificate program in medical records coding of at least 30 credits* or (e) a satisfactory equivalent combination of the foregoing training and experience but which must include the specialized coursework in medical terminology and ICD medical records coding or 6 credits* in anatomy and physiology.
Education: High school or equivalency diploma, required. An Associate's degree or Bachelor's degree in health information management preferred.
Licenses / Certifications: CPC, CPC-A, COC, CCS or CCS-P credential, preferred.
Other: Good knowledge of medical terminology; working knowledge of the principles of the medical record system and its operation; working knowledge of the current HCPCS, CPT and ICD10 CM/PCS codes; ability to understand and code medical records; ability to communicate effectively both verbally and in writing; ability to effectively use computer applications such as spreadsheets, word processing, calendar and e-mail in order to perform work assignments; ability to read, write, speak, understand, and communicate sufficiently to perform the essential duties of the position.