This position is primarily responsible for advanced coding and the assignment of accurate ICD-9-CM and CPT4 procedural and diagnostic codes, MS-DRG's, POA's, and the abstraction of clinical information. Coder II's must also be capable of coding outpatient, series, and emergency medical records.
1. Review the medical record to assure specificity of diagnoses and procedures for code assignment that is compliant and provides data and optimal reimbursement for hospital and/or professional charges.
2. Researches and provides education to providers and staff regarding coding and compliance issues utilizing regulatory and medical informational resources.
3. Abstract information from medical records following established methods and procedures.
4. Identify problem documents and works with submitting departments to correct errors.
5. Performs coding, abstracting, and documentation audits.
6. Responds to other departments who use coded information, verifies codes and charges assigned by other departments for accuracy. May enter charge information when appropriate.
7. Understands the requirements for appropriate disclosure of information.
8. Collaborates with clinical staff, documentation specialists, and physicians to assure accurate documentation to enhance hospital case mix index for data capture and reimbursement.
9. Participates in cross regional teams to assist in development of forms and standardized processes and performs audit reviews as outlined by the PeaceHealth Coding Team standards and Organizational Integrity.
10. Maintains communication and relationships with PFS billing and reimbursement staff and management regarding issues affecting coding and charge capture. Instructs coding staff as to regulatory updates.
11. Performs other duties as assigned.
'X High school diploma or equivalent required.
'X Successful completion of medical terminology, anatomy and physiology courses required.
'X Successful completion of college based coding program.
'X Five years of directly related work experience abstracting and coding impatient or ambulatory surgery records using ICD-9 CM and CPT-4 coding systems required. Knowledge of acute care and critical access reimbursement requirements.
'X RHIT (Registered Health Information Technology), RHIA (Registered Health Information Manager) and/or CCS (Certified Coding Specialist) preferred.
'X Ability to maneuver through multiple computer applications including encoders, abstracting, groupers, EMR and MS Office applications including Excel and Word required.
'X Effective written and verbal communication skills.
'X Critical thinking and problem solving skills required.
'X Ability to understand and carry out instructions furnished in written, verbal or diagram form.
'X Demonstrated good judgment and decision making skills.
'X Good organizational skills and attention to detail.
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