Coder - Medical Records

Brief Description

Under the supervision of the Coding Manager of Health Information Services the coder is responsible for timely review of patient records in order to identify an appropriate selection of codes which will accurately reflect the reason for admission, extent of care received, and level of severity of illness.

Coder ensures that all data elements required for federal or state reporting and billing are collected and included in the patient's demographic record.

Duties and Responsibilities:

• Coding and Abstracting
• Reviews and screens the entire medical record to abstract designated statistical data and enters the information in the abstract database in a timely and accurate
• Codes and sequences and groups to appropriate APC after identifying the principle diagnosis and procedure as documented in the records in a timely, accurate and ethical manner for optimum reimbursement for outpatient and emergency department records for all payer types.
• Uses various software applications to analyze and ensure appropriateness of codes and sequencing and addresses any applicable edits.
• Contacts the physician and/or ancillary department when additional information is needed to accurately code the Enters holding reason in abstracting database.
• Keeps abreast of regulatory changes affecting coded information required by the Centers for Medicare and Medicaid Services, the Office of Statewide Health Planning Department, Uniform Billing requirements, Official Coding Guidelines and others, as
• Review encounters holding for billing on a regular basis and follow-up as necessary to ensure timely release of bill.
• Selects appropriate assignments for coding/abstracting from work queue based on daily
• Data Quality Coding
• Generates, evaluates, and distributes various coding and abstracting data related
• Follow-up and address discrepancies on the various coding and abstracting data related
• Ensures OSHPD corrections are worked appropriately and in a-timely
• Follows re-bill guidelines
• Routes identified registration errors as defined by process and enters holding reason in abstracting database.
• Other Duties
• Assists hospital staff, medical staff, public, and
• Plans, organizes, prioritizes, and coordinates work to achieve functional area goals and maximum productivity and efficiency on a day to day basis.
• Answers telephones consistent with Service Excellence standards, addresses and/or routes calls appropriately and in a timely manner.
• Protects the confidentiality of primary and secondary health records and releases information as mandated by law, professional standards, and the hospital's policies.

Accepts and carries out other miscellaneous duties and responsibilities as required for maintaining the services provided by Medical Records.

Knowledge, Skills and Abilities:

Knowledge

• Knowledge of Microsoft Office
• Knowledge of department policies, practices and
• Knowledge of medical diagnostic and procedural
• Understanding of disease processes, anatomy and physiology as necessary for assigning accurate codes.
• Knowledge of encoders and
• Knowledge of federal and state regulations and requirements which pertain to patient care
• Knowledge of Medical Records functions normally acquired through a minimum of 24 months of Acute Care Medical Records Department experience.

Skills

• Reads handwritten and transcribed documents in the medical record and interprets
• ICD-10-CM and PCS and CPT/HCPCS coding skills
• Correlate generalized observations and symptoms to a stated diagnosis to assign the correct
• Perform data entry accurately with use of a keyboard and
• Perform duties using computers for coding, abstracting, and related
• Effective oral and written communication
• Detail oriented and

Abilities

• Ability to learn advanced aspects of Coding and Reimbursement
• Ability to review and enter data into various computer
• Ability to review records and verify patient

Core Competencies: All AVH employees will effectively demonstrate these behaviors:

Accountability Action Oriented Customer Focused Compassion

Effective Communication Teamwork

Ethics & Values Integrity & Trust

Education

High school graduate or GED equivalent.

Completion of 1 semester of college level Medical Terminology Completion of college level Anatomy and Physiology Course.

Experience

One year of recent coding experience in an acute care facility or ambulatory care facility preferred.

Experience With ICD-10-CM And PCS And CPT/HCPCS Classification Required.

Certified Coding Specialist or Certified Professional Coder-Hospital preferred

Ability to adhere with AVH Leaves of Absence Policy

• Ability to adhere with AVH Paid Time Off (PTO) Policy
• Ability to adhere with AVH Recording of Hours Worked Policy
• Ability to adhere to the department dress code
• Ability to organize work and establish priorities
• Ability to expand on own initiative in performance of duties
• Skill and ability to follow the telephone etiquette/standards
• Conforms to AVH Standards of Excellence
• Ability to function effectively under pressure and meet time parameters
• Ability to communicate effectively while maintaining good working relationships with co­ workers, managers and other hospital staff
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVH
• Ability to maintain the confidentiality of patient, hospital and department information
• Ability to adhere to safety rules and regulations
• Safely and effectively uses all equipment necessary to carry out duties
• Ability to interpret and function under hospital and department policies and procedures
• Conforms with required and appropriate Joint Commission requirements
• Conforms with and supports hospital quality assurance and improvement guidelines
• Ability to participate effectively in department and hospital staff education
• Display a willingness to work as a team player
• Ability to give and support the highest level of patient/customer satisfaction at all times
• Supports and adheres to the values and mission statement established by the AVH Board of Directors

Ability to demonstrate knowledge and understanding of Corporate Compliance rules and regulations, complies with duty to report behavior standard, demonstrates understanding of purpose for Corporate Compliance hotline and importance of seeking guidance from a supervisor when in doubt regarding a possible corporate compliance issue

Physical Requirements and Working Conditions:

• Work is usually performed in a normal office environment and may require long periods in sedentary position performing one function.
• Frequent use of keyboard and video display terminal.

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

NOTE:THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB. THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.

Requirements

Education

High school graduate or GED equivalent.

Completion of 1 semester of college level Medical Terminology Completion of college level Anatomy and Physiology Course.

Experience With ICD-10-CM And PCS And CPT/HCPCS Classification Required.

Certified Coding Specialist or Certified Professional Coder-Hospital preferred