Job Summary Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be used for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
Responsibilities Review the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses, and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations.
Carefully review documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary service treatment records to ensure all pertinent diagnoses and procedures are recorded.
Translate all diagnostic and procedural phrases used by healthcare providers into coded form using procedure codes as required.
Use the Encoder software program to determine the codes for all diagnoses and procedures.
Determine sequencing to legally maximize reimbursement.
Assign the appropriate DRG.
Assign codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines.
Query physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
Understand and apply internal policy and procedure guidelines regarding how to phrase physician queries.
Assist the Coding Quality and Professional Manager with training of new coding staff related to hospital and professional coding guidelines, encoder and other software systems needed for the coding process, review coding guidelines annually, and make recommendations for change to improve coding and data management.
Communicate to the Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc. documented within patient records to ensure that appropriate diagnosis and procedure codes are selected and incorporated into hospital and professional coding guidelines.
Update and correct historical file data by completing and submitting claim action reports per the PHC4 quarterly report.
Work in conjunction with other areas within the revenue cycle and external departments and Geisinger to ensure coordinated activities with respect to all revenue cycle needs.
Work Environment Work is typically performed in an office environment. The employee is accountable for satisfying all job specific obligations and complying with all organization policies and procedures.
Relevant Experience Relevant experience may be a combination of related work experience and/or completed specialty training program (1 year of specialty training = 1 year relevant experience).
Position Details This posting reflects an opening for Coder I and we are seeking candidates for that position. Geisinger reserves the right to consider applicants for higher levels of this role to include Coder II and Coder III based on their skills, qualifications, and experience.
Certification Requirements for Level II and III One relevant certification from AHIMA or AAPC is required upon hire. Acceptable certifications include:
AHIMA (American Health Information Management Association)
Certified Coding Specialist (CCS)
Certified Coding Specialist – Physician-based (CCS-P)
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Coding Associate (CCA) – Candidates with only a CCA are required to obtain a CCS, RHIT, or RHIA within 12 months of hire.
All certifications are acceptable from AAPC except:
Scribe
Documentation
Instructor
International Credentials
Certified Professional Biller (CPB)
Revenue Cycle Management Specialist (RCMS)
Certified Value-Based Administrator (CVBA)
Certified Physician Practice Manager (CPPM)
Certified Professional Compliance Officer (CPCO)
Education High School Diploma or Equivalent (GED) – Required; Graduate from Specialty Training Program – Preferred.
Experience Minimum of 1 year of related work experience – Required.
Certification(s) and License(s) Relevant coding certification – Default issuing body.
Benefits We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.
Equal Employment Opportunity We are an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran. We are an affirmative action, equal opportunity employer; women and minorities are encouraged to apply.
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