Coder (Business Office)

Cass Regional Medical Center; Harrisonville (MO); On-site; USD 50,000 - 70,000; Full time

Job summary

Cass Regional Medical Center in Harrisonville, MO is seeking a full-time Health Information Coding Specialist to review outpatient encounters and assign ICD-10-CM/PCS and CPT-4 codes. The role emphasizes accuracy, adherence to coding guidelines, and collaboration with physicians and departments.

This position requires coding certification and meticulous attention to detail. The HIM department offers a stable work environment with opportunities to contribute to coding quality and compliance while

Qualifications

• ICD-10-CM/ICD-10-PCS and CPT-4 coding for encounters.
• Uses Trucode encoder for outpatient chart code selections.
• Verifies charges and physician orders according to coding guidelines.

Responsibilities

• Selects ICD-10-CM/PCS and CPT-4 codes for inpatient and outpatient procedures.
• Abstracts completed records with accurate information in required fields.
• Ensures codes are sequenced per government and payer rules.
• Compliance with medical coding guidelines and policies.
• Assists with audits as requested by HIM/Coding Coordinator.
• Answers department calls within three rings and routes issues as needed.
• Prepares records for scanning and prints separator sheets.

Skills

ICD-10-CM coding

ICD-10-PCS coding

CPT-4 coding

Medical terminology

Education

Coding certification (CPC/CPC-H/CCS/RHIT)

Tools

Trucode encoder

Job description

Job Details

Job Location: Harrisonville, MO 64701

Position Type: Full Time

Job Shift: Day

Primary Purpose: To provide customer service to both the internal and external customers of the Health Information Management Department in a timely fashion. Review all outpatient encounters, selecting appropriate ICD-10-CM* and ICD-10-PCS* codes to reflect the diagnoses and course of treatment.

Formal Policy-Setting Responsibilities

No formal responsibility. The policies associated with the job’s purpose and essential responsibilities are set by others.

Routine Decision Making

Selects ICD-10 CM* diagnostic codes and CPT-4 procedure codes for outpatient procedures, and ICD-10-PCS codes for inpatient procedures to obtain appropriate reimbursement. Coders also verify the correct charges are on the chart in accordance to physicians’ orders.

Formal Supervisory Responsibility

No formal supervisory responsibility.

Unusual Working Conditions

None.

ESSENTIAL RESPONSIBILITIES AND TASKS

• Codes records using ICD10-CM* coding guidelines and ICD-10-PCS procedure coding guidelines. Trucode Encoder. (85% of time)
• Determines appropriate ICD10-CM and ICD-10-PCS procedure codes for inpatient procedures and CPT-4 treatment codes for outpatient procedures, utilizing the Trucode encoder for all code selections on outpatient charts assigned.
• Abstracts completed records entering correct information in the required abstract field, with minimal errors, verifying other pre-entered fields bypassed.
• Making sure that codes are assigned correctly and sequenced appropriately as per government and insurance regulations.
• Complying with medical coding guidelines and policies.
• Following all medical necessity edits by communicating with departments on charging, documentation and sending physician queries.
• Coders may be involved in audit processes as needed by Health Information Management (HIM)/Coding Coordinator.
• Answers phone calls in accordance with departmental standards. (5% of time)
  • Answers both internal and external phone calls utilizing proper phone etiquette, within three rings, two rings preferred.
  • Refers unresolved patient/customer issues to the Health Information Management Coordinator.
  • Forwards calls appropriately 100% of the time.
• Prepares records for scanning as necessary (5% of time)
  • Prints separator sheets for encounters coded.
  • Places separator sheet appropriately with in encounter.
• Performs other duties as requested by HIM/Coding Coordinator. (5%of time)
  • Meet productivity and quality standards.
  • Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results.

ESSENTIAL PHYSICAL REQUIREMENTS

Sedentary Work: Lifting 10# maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Jobs are sedentary; if walking and standing are required only occasionally.

PHYSICAL DEMANDS

• Lifting: Raising or lowering an object from one level to another (includes upward pulling).
• Carrying: Transporting an object, usually holding it in hands or arms or on the shoulders.
• Pushing: Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions).
• Pulling: Exerting force upon an object so that the object moves toward the force (includes jerking).
• Hearing: Ability to determine audible communication.
• Handling: Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved).
• Fingering: Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling).
• Repetitive Motions: Substantial movements (motions) of the wrist, hands, and/or fingers.
• Speaking: Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
• Acuity, near - clarity of vision at 20 inches or less.

WORKING CONDITIONS

Inside: Worker spends approximately 95% or more of time inside.

QualificationsEducation

Registration Required for the Position: Coding Certification required. CPC, CPC-H, CCS, and/or RHIT

Required Knowledge

Required Knowledge: Extensive knowledge of medical terminology, anatomy and physiology. Working knowledge of ICD10-CM*.

Preferred Skills and Ability

Proficiency in computer skills. Good communication skills with some experience working with physicians. Ability to maintain a high level of integrity and confidentiality of medical information. Strict attention to detail.