The Medical Coder III position plays a critical role in ensuring accurate medical coding and documentation. This involves handling complex case scenarios, applying a combination of facility coding and professional coding, and aligning with industry standards like ICD-10-CM, CPT, and HCPCS codes. The coders will code inpatient facility and inpatient professional rounds and facilitate proper documentation and communication with medical staff to enhance compliance and coding accuracy.

Position Responsibilities:

Accurately assigns Evaluation and Management (E&M) codes, International Classification of Diseases, Clinical Modification (ICD-CM) diagnoses, ICD-10 Procedure Coding System (ICD-10-PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), modifiers, and quantities derived from medical record documentation (paper or electronic) for the professional and institutional (facility) components of inpatient facility discharges (stays); inpatient professional services to include attending (also known as Rounds), consultations, and concurrent services, and inpatient surgical and anesthesia procedures; and inpatient External Resource Sharing Agreement (ERSA) encounters. May also code ambulatory (i.e. Coder II) or outpatient (i.e. Coder I) encounters as directedReviews encounters and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that may cause inaccurate coding, medico-legal repercussions or impacts quality patient careIdentifies any problems with legibility, abbreviations, etc., and brings to the providers attentionEducates and provides feedback to providers and clinical staff to resolve documentation issues to support coding complianceAssigns accurate codes to encounters based upon provider responses to coding queriesActs as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Collaborates with and supports medical coding auditors, trainers, and compliance specialists in providing education and feedback to providers and staff.

Supports DHA coding compliance by performing due diligence in ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channelsUpon

DHA-MCPB

direction, utilizes MHS computer systems to remotely access patient records and assign codes for patient encounters in support of other MTFs.

Achieve and maintain DHA coding productivity and accuracy standards for the position The role is hybrid and requires onsite work to be performed at the Naval Medical Center in Portsmouth, VA (620 John Paul Jones Circle, Portsmouth, VA 23708). There is an opportunity to telework up to 4 times a week, with approval and after completing 30 days of service on site.