Outpatient Certified Coder

Role Overview

• Analyze medical records, extracting clinical, pathological, therapeutic and epidemiologic data in accordance with established ICD-10-CM coding principles and guidelines
• Assigns Codes and codes all diagnostic and operative information from the medical record using ICD-10-CM/ICD-10-CM, ICD-10 PCS, CPT, HCPCS coding classification systems and independently quality checks own work
• Assigning ICD-10 diagnosis codes, CPT validation, modifier assignment
• Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, and CMS, regional and local policy
• Evaluating, addressing and understanding CCI, LCD and NCD edits
• Ensure data is optimally coded for documentation capture, financial reimbursement, care planning, statistics and regulatory reporting
• Reviews medical records to determine accurate required abstracting elements (facility/client specific elements) including appropriate discharge disposition to ensure accurate reimbursement
• Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems
• Demonstrates knowledge of anatomy, physiology pharmacology and pathophysiology to interpret general medical classifications for coding discharge data.
• Ensures timely record availability by meeting established coding and abstracting CNE productivity and accuracy standards
• Communicates and resolves coding issues around documentation for appropriate follow-up and education
• Interacts and communicates with department lead and manager to clarify and accurately document patient diagnostic and procedural information
• Maintains and complies with policies and procedures for confidentiality of all patient records
• Performs other related duties as assigned

Requirements

• Must have at least three (3) years hospital experience within the last five years.
• This position has a preferred certification as a Certified Coding Specialist (CCS).
• A Certified Professional Coding certification will also be considered with additional years of experience.
• Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.
• Coding certification must be maintained on an annual basis.