Coder II

Overview

Job Description - Coder II )

Wythe County Community Hospital

Description

POSITION SUMMARY: Under the direction of the Health Information Management Director, the coder II accurately determines ICD-10-CM diagnosis codes, ICD-10-CM, CPT and HCPCS procedure codes for all patient types including inpatient, observation, surgical day care, Emergency Department (ED) outpatient and recurring patients.

• Abstract pertinent information from patient records within various inpatient and outpatient types. Assign ICD-10-CM/ ICD-10-PCS codes or HCPCS codes, creating ambulatory payment classification (APC) or diagnosis related group (DRG).
• Monitor and manage the discharged not final billed (DNFB) accounts within assigned patient types daily to meet financial goals and expectations.
• Meet coding productivity standards and accuracy rate determined by company policy. (See Coding Productivity and Quality Standards.)
• Query clinical staff to achieve accuracy in coding.
• Closely communicate with the clinical documentation specialist and advise on coding rules and guidelines; support the clinical documentation improvement program.
• Educate, train and communicate with medical staff regarding accurate documentation for coding purposes.
• Keep abreast of coding guidelines and reimbursement reporting requirements. Bring identified concerns to supervisor or department manager for resolution. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding guidelines.
• Abstract data and reports to the Virginia Trauma Registry.
• Participate in the appeals process for coding denials. Initiate and respond to requests for billing to support medical necessity, appropriateness of code assignment, payer requirements, and other activities to support the billing function.
• Answer telephone and respond to requests in a professional, timely manner.
• Maintain professional credentials through ongoing coding education as well as company requirements for annual continuing education.
• Contribute to quality improvement activities of the department and the organization, including participation in internal department and corporate audits.
• Participate in other department or organizational activities as requested.

• Effective oral and written communication skills
• Demonstrated competence with personal computers, networks, and Microsoft Office
• Experience with various coding abstracting and coding systems
• Ability to work independently or as a team member to accomplish tasks or projects
• Ability to prioritize work assignments during periods of stress
• Ability to sit for long periods of time
• Corrected visual acuity for long periods of reviewing/reading medical records and viewing a computer monitor
• Knowledge and skills to correctly assign principal diagnosis for inpatients and reason for visit/first listed diagnosis for outpatient encounters; correctly assign additional diagnoses based on coding rules and guidelines
• Critical thinking, time management, and organizational skills

Age Specific

Definition

Yes

No

Birth to One Year
• Infant

2 – 3 Years
• Toddler

4 - 5 Years
• Pre-Schooler

6 – 11 years
• School Age

12 - 17 years
• Adolescent

18 – 30 years

31 – 64 years
• Adult

65+
• Geriatric

No responsibility to treat or care for patients

Exposure to: None, Some, Frequent

Typical exposure indicators are listed below.

• Toxic/caustic chemicals – X
• Dust/fumes/gases/helicopter – X
• Moving mechanical parts – X
• Blood or Body Fluids – X
• Communicable Diseases – X
• Potential electrical shock – X
• X-ray electromagnetic energy – X
• Needles or sharp objects – X
• Frequent repetitive motions – X
• Use/viewing of Computer monitor – X
• Unprotected heights – X
• Physically or verbally abusive patients – X
• Hazards in patients’ homes – X
• Extreme heat or cold – X
• 50% of time spent traveling –
  exposure
• Exposure to high pitched noises – X

Sedentary Work
:
Lifting 10 lbs. maximum and occasionally lifting and/or carrying articles.

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Light Work
:
Lifting 2 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 10 lbs.

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Medium Work
:
Li…