Utilizes technical coding expertise to assign appropriate ICD-10-CM and CPT-4 codes to outpatient visit types.
Reviews the medical record thoroughly, utilizing all available documentation to code appropriate diagnoses and procedures.
Interprets health record documentation using knowledge of anatomy, physiology, clinical disease process, pharmacology, and medical terminology to report appropriate diagnoses and/or procedures.
Sends appropriate physician queries when required for documentation clarification.
Follows Coding Clinic for HCPCs, CPT Assistant, and interprets coding conventions and instructional notes to select appropriate diagnoses and procedures with a minimum of 95% accuracy.
Provides technical expertise to analyze system related changes and participates in testing of software modifications.
Identifies opportunities to enhance CAC (computer assisted coding), notifying IT liaison of documents filing to Default folder, incorrect system assigned codes, etc.
Utilizes 3M Encoder resources to ensure optimal coding accuracy.
Requirements
Credentialed by the AHIMA (American Health Information Management Association)
CE requirement to remain credentialed is 20-30 CE's every two years
3-4 years of coding experience in an acute healthcare setting