Coder II

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 utilized 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.

• Reviews 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 details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
• Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using procedure codes as required.
• Using the Encoder software program, determines the codes for all diagnoses and procedures.
• Determines their sequencing to legally maximize reimbursement.
• Assigns the appropriate DRG.
• Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines. Queries physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
• Understands and applies internal policy and procedure guidelines regarding how to phrase physician queries.
• Assists 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, along with reviewing coding guidelines on an annual basis and makes recommendations for change to improve coding and data management.
• Communicates to 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.
• Updates and corrects historical file data by completing and submitting claim action reports per the PHC4 quarterly report.
• Works 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.

* 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).

• Certification required:
  • Certified Risk Adjustment Coder – American Academy of Professional Coders (AAPC)
  • Certified Professional Coder (CPC) – American Academy of Professional Coders (AAPC)
  • Registered Health Information Technician (RHIT) – American Health Information Management Association
• Education High School Diploma or Equivalent (GED) – Required.
• Experience Minimum of 3 years relevant experience – Required.
• Certification(s) and License(s)
  • Registered Health Information Technician (RHIT) – American Health Information Management Association
  • Certified Risk Adjustment Coder – American Academy of Professional Coders (AAPC)
  • Certified Professional Coder – American Academy of Professional Coders (AAPC)

• Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.
• KINDNESS:
  We strive to treat everyone as we would hope to be treated ourselves.
• EXCELLENCE:
  We treasure colleagues who humbly strive for excellence.
• LEARNING:
  We share…