The Coder II is responsible for conversion of diagnosis and treatment procedures into codes utilizing the current Revision of the International Classification of Diseases and Operations, Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPT-4), Evaluation and Management (E&M), and HCPCS coding for Professional (Physician) services received in the CMH Health Services system. Requires skill in the sequencing of diagnosis/procedures to optimize reimbursement and compliance to documentation and medical policy guidelines for all payers. Ensures that records are coded in an accurate and timely manner. Performs audits on chart information, level of care charged and provides education to staff and providers on compliant coding.
General duties, tasks and responsibilities include ensuring that records are coded accurately and timely; reviewing patient charges for inconsistencies; contacting physician if diagnosis is not available on chart; referring charts accordingly. Utilizes computerized coding/abstracting equipment, coding software, coding references and resources, transcription equipment, and medical dictionaries to ensure the most accurate and efficient entry of information. Codes all diagnoses/procedures in accordance to ICD-10-CM/PCS coding principles and the Coding Manual; ensures data quality and optimum reimbursement allowable under the federal and state payment systems are obtained. Consistently meets or exceeds department productivity standards for daily work assignments. Meets or exceeds department quality standards for selecting principal diagnoses and procedures appropriately and/or correctly and coding accordingly. Maintains the number of DRG/coding changes below department standards on a quarterly basis per PRO threshold. Understands medical/legal implications of incorrect coding and the responsibility of the certified coder to ensure coding accuracy. Complies with all established safety procedures to ensure a safe environment for patients, visitors and staff. Participates in performance improvement activities. Performs other duties as assigned.
Education requirements include an Associate's Degree in related field / Equivalent combination of education and experience Required.
Certification/Licensure requirements include RHIA, RHIT, CCS, CCS-P or CCA Coding Certification Required.
Experience requirements include hospital medical coding minimum 3 years preferred.
Computer skills include strong computer skills including Microsoft Word, Excel and Outlook.
Additional skills include ability to work independently, prioritize and complete tasks in a timely manner; knowledge of diagnoses/procedures in accordance with ICD-10-CM/PCS coding principles; knowledge of medical terminology, anatomy and physiology.