Coder II, HIM - HIM Financial Non-Exempt; Non-Union

Coder II, HIM - HIM Financial - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

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In accordance with federal coding compliance regulations and guidelines, use current ICD-10-CM, CPT-4, and HCPCS code sets/systems to accurately abstract, code, and electronically record into the 3M Coding & Reimburse System (3M-CRS) & the coding abstracting system (3M-Clin Trac), all diagnoses, surgical procedures, and other significant invasive and non‑invasive procedures documented by any physician in outpatient medical records (i.e. OP Ancillary/Clinic Visits, and an assorted outpatient surgeries: GI Lab, Heart Cath Lab, Pain Management surgery, and Invasive Radiology, etc.).

Address OCE/NCCI edits within 3M-CRS and those returned from the Business Office. Understands PFS coding/billing processes & systems such as PBAR and nThrive/Med Assets/XClaim in a manner to assure claims drop timely with appropriate codes. Performs other coding department related duties as assigned by HIM management staff.

• Ambulatory Surgery coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions.
• Reviews the entire medical record; accurately classify and sequence diagnoses and procedures; ensure the capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co‑morbidities, historical condition or family history that has an impact on current care or influences treatment, and all external causes of morbidity.
• Enter patient information into inpatient and outpatient medical record databases (Clin Trac/HDM). Ensures accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission.
• Works cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist in obtaining documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes.
• Assists in the correction of regulatory reports, such as OSHPD data, as requested.
• Attendance, punctuality, and professionalism in all HIM Coding and work related activities.
• Consistently assumes responsibility and displays reliability for completion of tasks, duties, communications and actions. Completes tasks accurately, legibly, and in a timely fashion.
• Performs other duties as requested/assigned by Director, Manager, Supervisor, or designee.
• Ability to achieve a minimum of 95% coding accuracy rate as determined by any internal or external review of coding and/or department quality review(s).
• Ability to achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by any internal or external review of coding and/or department quality review(s).
• Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting.
• Recognizes education needs of based on monthly reviews and conducts self‑improvement activities.
• Ability to act as a resource to coding and hospital staff on coding issues and questions.
• Ability to improve MS-DRG assignments specific to the documentation & coding of PDx, Sec Dx, CC/MCC, PPx, and Sec Px in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APR-DRG, SOI, and ROM assignments specific to the documentation & coding of PDx, Sec Dx, CC/MCC, PPx, and Sec Px in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APC/HCC assignments specific to medical necessity documentation & coding of PDx, Sec Dx, and CPT/HCPCS in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Maintains at minimum, expected productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of…