Medical Records Coder - Remote
DOMA Technologies LLC - Virginia Beach, VA

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Summary of Position

Coder will perform remote coding services, coding/documentation feedback and reporting for services on Outpatient, Emergency Department, Inpatient, Inpatient Rounds and/or Ambulatory Procedure Visit (APV) medical records documentation, and provide educational feedback to coders and physician’s addressing inappropriate patterns of documentation of records audited.

This is a Service Contract Act (SCA) covered position.

Essential Duties and Responsibilities
  • Reviews and verifies component parts of medical record to ensure completeness and accuracy of diagnosis, operations, and special therapeutic procedures that must conform to Health Care Financing Administration and Department of Defense Coding Guidelines.
  • Codes principal diagnosis, co- morbidities, complications, therapeutic and diagnostic procedures, supplies, materials, injections, and drugs, etc. with ICD-9-CM, CPT and HCPCS — all levels, and any other coding classification systems that may be required by the DOD.
  • Personnel shall identify the correct principal diagnosis and principal procedure based on physician's attestation record documentation and established sequencing rules and guidelines. Ensure proper sequencing of ICD-9-CM codes to obtain proper resource allocation based on the DRG. Identify additional diagnoses/procedures; i.e., complications, co-morbidities, therapeutic procedures and diagnostic procedures.
  • Submits coder productivity spreadsheets to the project manager without discrepancies.
  • Process an average per hour:
    • 15 outpatient clinic encounters
    • 10 emergency department encounters
    • 2.5 inpatient records
    • 10 inpatient round encounters
    • 5 ambulatory procedure visit encounters
  • Clinic encounters unable to be coded due to administrative errors shall be returned to the project manager who will return them to the specific departments for correction.
  • Protect the confidentiality of primary and secondary health records and the information therein as mandated by law, professional standards and hospital policies IAW MEDCEN regulation 40-52 and AR 40-66. The employee shall comply with the Privacy Act, 38 USC 5701 and USC 7332.
  • The employee will be audited by the data quality manager for accuracy of coding. The ICD-9 coding books (ICD-10 when applicable); Fay Brown’s ICD-9 (ICD-10 when applicable) guidelines coding handbook, coding clinic, CPT (Current Procedural Terminology) Assistant and/or CCE equivalent references, and Military Health Systems (MHS) Professional Coding Guidelines will be used to determine the 95% accuracy required.
  • The performance standards shall be: To code 100% of records assigned within 7 calendar days of patient encounter for outpatient clinic encounters than have never been coded/audited. Required completion of medical records per DoD is 30 calendar days from discharge for ITRs, under 30 calendar days from the date of the IPSR RND, and under 15 calendar days for APVs.
  • Coding shall be conducted using the following guidelines/publications:
    • International Classification of Diseases, Ninth Revision, Clinical Modification, issued by the US Department of Health and Human Services (ICD-9-CM)
    • Current Procedural Terminology, Forth Edition (CPT-4)
    • Coding Clinic for ICD-9-CM, CPT-4 Assistant
    • National Naval Medical Center and Department of Defense Specific Coding Guidelines
  • No overtime requirement for this position.
  • No travel required for this position.
  • If no records are available to code, coder shall take PTO or LWOP for hours not actively productive with average encounter workload as outlined above.

Supervisory Responsibilities

This job has no supervisory responsibilities.

  • Certified Medical Coder(s), Certified Coding Specialists (CCS), Certified Coding Specialist(s)-Physician based (CCS-P), Certified Professional Coder(s) (CPC), Registered Health Information Administrator(s), (RHIA) and Registered Health Information Technician(s) (RHIT) as necessary to code medical record data.
  • Recent experience performing similar functions in tertiary care medical centers is also required.
  • Minimum of 2 years of continuous coding experience required.
  • Must be able to attain and maintain a favorable adjudication for a National Agency Check with Inquiries (NACI) background check
  • Knowledge of current and developing issues and trends in medical coding.
  • Ability to analyze, problem-solve, and work independently effectively. Strong communication and interpersonal skills.
  • Ability to provide guidance and training to professional and technical staff in area of expertise.

Additional Requirements
  • Ability to analyze, problem-solve, and work independently effectively.
  • Strong communication and interpersonal skills.
  • CCE/ AHLTA/ Essentris/ CHCS/ 3M knowledge preferred.
  • Knowledge of current and developing issues and trends in medical coding.
  • Attention to detail and data entry accuracy is essential.
  • Must be able to sit, verbally converse and work on a computer for long periods of time with or without reasonable accommodation
  • Frequent use of hands/fingers across keyboard or mouse or handling other objects.

Work Environment

Coders will be located in remote offices. Computer, books, references material provided to coder to fulfill task.

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