Primary Purpose:

To provide customer service to both the internal and external customers of the Health Information Management Department in a timely fashion. Review all outpatient encounters, selecting appropriate

ICD-10-CM

• and

ICD-10-PCS

• codes to reflect the diagnoses and course of treatment.

Formal Policy-Setting Responsibilities:

No formal responsibility. The policies associated with the job's purpose and essential responsibilities are set by others.

Routine Decision Making :

Selects

ICD-10 CM

• diagnostic codes and CPT-4 procedure codes for outpatient procedures, and

ICD-10-PCS

codes for inpatient procedures to obtain appropriate reimbursement. Coders also verify the correct charges are on the chart in accordance to physicians' orders.

Formal Supervisory Responsibility:

No formal supervisory responsibility.

Unusual Working Conditions:

None.

ESSENTIAL RESPONSIBILITIES AND TASKS

Codes records using

ICD10-CM

• coding guidelines and

ICD-10-PCS

procedure coding guidelines. Trucode Encoder. (85% of time) Determines appropriate ICD10-CM and

ICD-10-PCS

procedure codes for inpatient procedures and CPT-4 treatment codes for outpatient procedures, utilizing the Trucode encoder for all code selections on outpatient charts assigned. Abstracts completed records entering correct information in the required abstract field, with minimal errors, verifying other pre-entered fields bypassed. Making sure that codes are assigned correctly and sequenced appropriately as per government and insurance regulations. Complying with medical coding guidelines and policies. Following all medical necessity edits by communicating with departments on charging, documentation and sending physician queries. Coders may be involved in audit processes as needed by Health Information Management (HIM)/Coding Coordinator. Answers phone calls in accordance with departmental standards. (5% of time) Answers both internal and external phone calls utilizing proper phone etiquette, within three rings, two rings preferred. Refers unresolved patient/customer issues to the Health Information Management Coordinator. Forwards calls appropriately 100% of the time. Prepares records for scanning as necessary (5% of time). Prints separator sheets for encounters coded. Places separator sheet appropriately with in encounter. Performs other duties as requested by HIM/Coding Coordinator. (5%of time) Meet productivity and quality standards. Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results.

ESSENTIAL PHYSICAL REQUIREMENTS

Sedentary Work:

Lifting 10# maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Jobs are sedentary; if walking and standing are required only occasionally.

PHYSICAL DEMANDS

Lifting:

Raising or lowering an object from one level to another (includes upward pulling).

Carrying:

Transporting an object, usually holding it in hands or arms or on the shoulders.

Pushing:

Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions).

Pulling:

Exerting force upon an object so that the object moves toward the force (includes jerking).

Hearing:

Ability to determine audible communication.

Handling:

Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved).

Fingering:

Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling).

Repetitive Motions:

Substantial movements (motions) of the wrist, hands, and/or fingers.

Speaking:

Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. Acuity, near - clarity of vision at 20 inches or less.

WORKING CONDITIONS

Inside:

Worker spends approximately 95% or more of time inside. Education and Certification/ Registration Required for the

Position :

Coding Certification required. CPC, CPC-H, CCS, and/or

RHIT Required Knowledge:

Extensive knowledge of medical terminology, anatomy and physiology. Working knowledge of

ICD10-CM

•.

Preferred Skills and Ability:

Proficiency in computer skills. Good communication skills with some experience working with physicians. Ability to maintain a high level of integrity and confidentiality of medical information. Strict attention to detail.