Job Description - Coder II (7454-1498)
Wythe County Community Hospital
POSITION SUMMARY
Under the direction of the Health Information Management Director, the coder II accurately determines ICD-10-CM diagnosis, and ICD-10-CM, CPT and HCPCS procedure codes for all patient types to include inpatient, observation, surgical day care, Emergency Department (ED) outpatient and recurring patients.
POSITION RESPONSIBILITIES
Abstract pertinent information from patient records within various inpatient and outpatient types. Assign International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) / International Classification of Diseases, Tenth Revision, Clinical Modification Procedural Coding System (ICD-10 PCS) codes or Healthcare Current Procedural Coding System (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.)
Queries clinical staff to achieve accuracy in coding
Closely communicates with the clinical documentation specialist and advises on coding rules and guidelines and supports the clinical documentation improvement program.
Educate, train and communicate with medical staff regarding accurate documentation for the purposes of coding.
Keep abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
Abstracts 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, combining accounts based on 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.
Contributes to quality improvement activities of the department and the organization, including participating 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
AGES OF POPULATION SERVED
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.
Hazards: Toxic/caustic chemicals, Dust/fumes/gases/helicopter, Moving mechanical parts, Blood or Body Fluids, Communicable Diseases, Potential electrical shock, X‑ray electromagnetic energy, Needles or sharp objects, Frequent repetitive motions, Use/viewing of Computer monitor, Unprotected heights, Physically or verbally abusive patients, Hazards in patients’ homes, Extreme heat or cold, Exposure to high pitched noises.
50% of time spent traveling.
PHYSICAL DEMANDS / LIFTING REQUIREMENTS
(X) 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; Working in confined area; Ability to distinguish Colors; Standing/Walking > 25%, > 50%, > 75%; Multi‑tasking, ability to work with frequent interruptions; Hand/eye coordination; Use of Computer > 75%; Critical Thinking Skills; Reaching above shoulder level; Climbing on Ladder; Operating Motor Vehicle or motorized equipment.
POSITION REQUIREMENTS
Post high school specialty or vocational training with 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 an APP-approved program.
Minimum of 3 years of acute hospital coding and abstracting experience.
Experience and/or education in ICD-10 CM/ICD-10 PCS coding.
Certification or licensure as:
Certified Coding Specialist (CCS) (or obtain CCS credential within 2 years of employment – required).
Registered Health Information Administrator (RHIA).
Certified Professional Coder-Hospital (CPC-H).
Must obtain the CCS credential within 2 years of employment or have equivalent acute care coding and abstracting experience.
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