A Medical Coder organizes and reviews patient medical records and assigns codes for each diagnosis and treatment. Prepares coded information for use by health care insurers or for research. May retrieve information for clinicians and billing offices. Works in healthcare facilities.
The Coder is responsible to review, abstract, assign appropriate ICD10-CM, CPT and DRG codes as needed to all patient charts/accounts. Assists the revenue cycle team by performing audits to detect, assess and resolve re-imbursement and revenue compliance concerns. Involved in the charge capture process.
RESPONSIBLE TO
System Director of Revenue Cycle
MUST HAVE REQUIREMENTS
Previous coding experience / knowledge. Ability to follow written and verbal directions. Knowledge of state and federal coding regulations. Knowledge of Anatomy, Physiology, Disease Processes, and Medical Terminology. RHIT/RHIA/CCS/ or CCA eligible. If not credentialed at time of hire, then applicant must become credentialed in one of the four areas within 12 months of hire to remain employed. Ability to operate computer on a daily basis and perform basic office procedures. No written disciplinary action within the last 12 months.
PREFERRED ATTRIBUTES
Completion of an accredited program in Health Information Technology. Denotes ADA Essential Follows Appropriate Service Standards
POSITION EXPECTATIONS
Reviews charts of all inpatient, outpatient surgeries, observations, clinic, special procedures, emergency room records, and outpatient testing or treatment room records, etc. on a daily basis in order to assign proper ICD10-CM and/or CPT codes for billing and statistical reports. Utilizes encoder software to code and finalize bill Able to prioritize most needed coding and code in a timely manner. Abstracts demographic information as needed. Works with Manager with problem accounts. Tracks down these accounts and works with the physician to complete these records and codes them for billing. Reports any problems in coding, billing or registrations to the Manager. Ensures that chart information supports the diagnosis and treatment. Charts must be thoroughly reviewed and discrepancies communicated to the physician for correction or further documentation. Performs audits of revenue cycle processes utilizing reports from various software applications (i.e. Craneware, Meditech, Quadex, etc.) and report findings to the Manager. Must be able to perform audits utilizing all source documents, including the medical record, itemized charges, UB92 and charging worksheets. Performs revenue audits for clinical departments on a rotating basis as well as requested audits on an as needed basis. The need for an audit can be identified by PFS, HIM or clinical departments. Performs charge capture processes for the specified categories of charges. 4/95
