Coding Specialist IV - Coding - HIM
Coding - HIM
- This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance.
All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center.
Under the general direction of the Coding and Clinical Abstracting Manager, this certified coding specialist is responsible for accurate coding of diagnosis and procedures for all inpatient, observation, and outpatient surgery records, working from the appropriate documentation in the medical record of the patient. Classification systems include ICD-9-CM and CPT-4. The Coding Specialist IV works with physicians and professional staff to obtain any necessary clarification concerning diagnosis and procedures, writing queries, charge referrals and medical necessity referrals as needed and according to facility guidelines. He/She is responsible for monitoring the Discharges Not Final Billed (DNFB) list and plays an active role in meeting the organization’s financial goals. Possesses an understanding of OPPS, and APC reimbursement and the application of Local and National Coverage Determinations (LCD/NCDs). This person requires little supervision and performs all work independently, with a high degree of autonomy. All work is carried out in accordance with the department’s approved policies and procedures. This position is an advanced level certified technical position within the Coding Department.
PRIMARY JOB DUTIES:
1. Codes all diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter, and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management Association and all governmental and private Third Party rules and regulations.
2. Abstracts patient information from records of all assigned accounts and enters appropriate data elements into the computerized abstracting system.
3. Works with Clinical Documentation Specialists and Reimbursement Specialists to identify areas for improvement in physician documentation and collaborates on educational initiatives regarding documentation and DRG/APC assignment.
4. Consistently meets the minimum coding productivity requirements per hour (2.5 inpatient, 6 OP Surgery/Observation) while maintaining at least a 95% accuracy rate.
5. Works with physicians and professional staff to obtain any necessary clarification concerning diagnosis and procedures, writing queries, charge referrals and medical necessity referrals as needed and according to facility guidelines.
6. Prepares workload reports and plays an active role in meeting the departmental and organizational goals.
7. Promotes customer satisfaction through prompt and courteous service.
8. Fosters respect for patient privacy by maintaining confidentiality in all phases of work.
9. Completes continuing education required to maintain credential.
10. Performs those duties necessary to ensure all accounts are processed accurately and timely.
11. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
12. Performs other duties as assigned.
ESSENTIAL JOB SPECIFICATIONS:
1. Education: High School Diploma required. B.S degree or A.A. degree in Health Information Management preferred. Extensive knowledge of ICD-9-CM and CPT coding required. Advanced medical terminology, clinical medical concepts, and human anatomy and physiology required. Education may be through formal programs of study or through sequenced in-service training.
2. Licensure / Certifications: AHIMA credentialed Certified Coding Specialist (CCS) required, combined with RHIT, RHIA preferred.
3. Experience: Three-Five years in coding/abstracting using ICD-9-CM and CPT-4 in an acute care hospital based setting required.
New Hanover Regional Medical Center - 18 months ago