Coding Specialist Level II
Data management functions in a variety of application areas; including clinical coding, outcomes management, and specialty registries. Reviews medical records to confirm diagnoses and apply appropriate disease and procedure codes. Abstracts and analyses records for appropriateness of documentation for assigning DRG. Enters data into computer system to produce documentation required for correct patient billing. Assists in protecting legal interests of the patient, hospital and physician. Data Entry, and retrieval of data for the purpose of statistical reporting.
1. * Examines the medical record for consistency and accuracy of identifying information; reports any discrepancies or problems to supervisor.
2. * Reviews medical record to determine all diagnoses and procedures in order to assign the appropriate codes.
3. * Assigns and sequences ICD-9-CM diagnostic and procedural coding on all cases and utilizes AHIMA coding guidelines (i.e., establishes principal and secondary diagnoses and procedures).
4. * Abstracts data required by federal and state regulatory agencies (e.g., physician information, patient demographics) and enters into hospital computer system.
5. * Analyzes for optimization and DRG assignments utilizing Encoder.
6. * Identifies documentation specifics to support the diagnoses; provides the supervisor with the information to be communicated to the physicians.
7. * Carries out all quality control procedures required by the department to ensure the accuracy of data.
8. * Meets the required daily coding and competency levels established for inpatient medical records (20-23 records with error rate < 3%)
9. * Meets required coding and competency standards for Ambulatory Surgical records. (30-35 amb/sur records with error rate < 3%)
10. *Inserts tumor registry forms in record when required.
11. *Competes DOH forms for appropriate records, i.e. Alzheimer’s and CMR .
12. Responsible for submitting DOH forms to the responsible person in a timely manner.
13. *Assigns charts to appropriate review area for quality check.
14. Participates in the quality improvement process of the department and/or medical center.
15. Participates in the educational programs and inservice meetings to enhance skills and development as demonstrated by record of inservice/continuing education.
16. Maintains and enhances professional growth and development through educational programs, workshops, and professional affiliations.
17. * Maintains established departmental pollicies and procedures, objectives, compliance program, confidentiality, safety, environmental, and infection control standards.
18. *Assists in selecting, training, assigning, and monitoring staff; evaluates performance; and makes recommendations for personnel action.
19. *Acts as a resource to other staff on coding issues.
- Indicates an Essential Job Function.
OTHER JOB DUTIES
Identifies records needed for special studies (e.g., data collection or government agencies); prints list of records and gives to requestor.
Perform other related duties as assigned.
High School Diploma or equivalent
Successful completion of a coding program ICD-9, CPT-4 recognized by the American Health Information Management Association.
CCS, CCS-P, RHIT, or RHIA preferred.
Comprehensive knowledge of ICD-9-CM and CPT-4 classification systems, Anatomy and Physiology.
Demonstrated skill in ICD-9-CM coding conventions, UHDDS abstractions requirements and NYS & JCAHO record documentation required.
Minimum of 2 years prior clinical coding experience required.
*Productivity: inpatient records – 20-23 med/sur records, amb/sur records – 30-35 records.
Accuracy rate: >97%*
Must pass Coding Competency Test
Must pass basic data entry skills test
Spreadsheet/word processing experience
Good oral and written communication skills
Good interpersonal skills
Speaks, reads and writes English to the extent required by the position
JOB SETTING/PHYSICAL DEMANDS
Medical Records office, contact with medical staff and vendors.
Professional appearance and demeanor
Mostly sedentary with occasional reaching, stooping, bending, kneeling
POTENTIAL EXPOSURES (Category I, II, III)
Body Fluid Radiation