Coder - Hospital

Position: Coder 2 - Hospital
Abstracts all Emergency procedures utilizing the International Classification of Disease, Clinical Modifications (ICD-9-CM) system and the Current Procedure Terminology (CPT-4)/HCPCS guidelines for code assignments. Determines and enters charges for ER facility procedures and ER visit levels.

* Coding and Documentation

* Reviews medical record documentation to validate procedure charge indicated by nursing staff and accurately enters charges for procedure selected on chart ticket.

* Accurately assigns appropriate procedure codes to emergency room patient records using ICD-9-CM system and CPT-4/HCPCS coding guidelines. Using 3M system, abstracts data elements related to procedures performed in the emergency department. Determines the appropriate sequencing of procedures.

* Accurately and completely appends modifiers to CPT/HCPCS codes as required.

* Accurately and completely posts charges for Drug Administration services (injections and infusions) in compliance with regulatory drug administration guidelines. Units of service are correctly selected.

* Assists the Business Office and external agencies in clarification of coding regarding reimbursement issues. Handles all requests in a timely fashion.

* Quality

* Utilizes nurses (Lynx) charge ticket to accurately and efficiently enter charges for evaluation and management (E&M) facility visits.

* Consistently places records on pending diagnosis code status to prevent premature bill drop.

* Maintains an accuracy rate of not less than 93% based on internal and/or external review and productivity standards, engages in problem identification and resolution, and assists in data gathering and chart auditing as necessary.

* Participates in educational programs (including those provided and required by the Health Information Management Department), in-services and training sessions as required. When appropriate, the Coding/Billing Specialist shares his/her own expertise with others in an effort to further the quality of education and personal growth provided to new personnel, volunteers and interning students.

* Collaboration and Partnership

* Communicates with the appropriate ER staff members when records with missing information are identified.

* Demonstrates competencies in the service to our patients/customers of all ages by obtaining information in terms of customer needs. Speaks in a positive, professional manner about co-workers, physicians, and the facility.

* Collaborates with Emergency Room nursing personnel and physicians. Provides education and initiates process improvement opportunities to eliminate discrepancies between charge ticket and Medical Record documentation.

* Consults with HIM Coding Supervisor and/or HIM Director in matters of uncertainty regarding coding.

* Consults with Revenue Management Department staff regarding charge master or charging issues.

* Other Duties As Assigned

* Performs other duties as assigned or requested.

Experience - RHIT/RHIA plus 2 years of acute care coding experience, or 4 years acute care coding experience; RHIT/RHIA with ICD-10 curriculum substitutes for all experience; CCS substitutes for 1 year of acute care coding experience;
Associates or Bachelors degree in Allied Health or Health Information Systems can substitute for minimum years of experience.

Education - High School diploma or equivalent