Coder Senior

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 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.
• 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.
• Provides and arranges training for coding professionals in the use of coding guidelines and practices, proper documentation techniques, medical terminology, and disease processes.
• Completes coding quality audit reviews to ensure all available cases were coded and entered into the hospital and professional computer system correctly and initiates Claim Action Reports as necessary.
• Develops coding policy and procedure or position papers related to correct coding for new or emerging technology services provided by clinical staff, and train coders on the use of that policy and procedure.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

* 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).

Minimum of one of the following certifications is required:

• Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC)
• Certified Risk Adjustment Coder (CRC) - American Academy of Professional Coders (AAPC)
• Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)
• Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA)

Education:

High School Diploma or Equivalent (GED) – Required

Experience:

Minimum of 7 years – Relevant experience*

Certification(s) and License(s):
Registered Health Information Technician (RHIT) – AHIMA;
Certified Professional Coder – AAPC;
Certified Coding Specialist – AHIMA;
Certified Risk Adjustment Coder – AAPC

Everything we do is about caring for our patients, our members,…