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Basic Function
Reviews patient records and assigns accurate codes for each diagnosis and procedure on the accounts assigned to the coder. Applies knowledge of medical terminology, disease processes, and pharmacology. Demonstrates tested data quality and integrity skills. Performs chart verification as assigned. Performs final chart reviews as necessary.
Shift Days/Hours
Remote Position
- Part-Time: 20-32 Hours per Week
- Full-Time: 40 Hours per Week, Monday through Sunday
- PRN: As needed
Hours and Days are Subject to change based on business necessity.
Essential Functions
- Review and abstract patient medical records. Report diagnoses, treatments, as well as surgical and non-surgical procedures for CAH facility medical services.
- Perform coding duties of discharged patient medical records using AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, AHA Coding Clinic for HCPCS, CMS ICD-10-CM Official Guidelines for Coding and Reporting, AMA CPT Assistant, and ACEP ED Facility Level Coding Guidelines.
- Correctly assign ICD-10-CM/PCS and CPT/HCPCS codes creating APG group assignments.
- Abide by the standards of American Health Information Management Association (AHIMA) Standards of Ethical Coding. Concerns involving compliance issues are forwarded to the Manager of HIM for action.
- Abide by the standards of American Health Information Management Association (AHIMA) Code of Ethics. Concerns involving compliance issues are forwarded to the Manager of HIM for action.
- Apply accurate charges.
- Query physicians when documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
- Report unusual findings to the supervisor when coding.
- Ensure code assignment is supported by provider documentation.
- Maintain professional competency and knowledge of third-party payer and QIO regulations.
- Be compliant with HIPAA, demonstrating discretion and integrity.
- Work with minimal supervision.
- Other duties as assigned.
Qualifications
- Education: A minimum of high school diploma plus successful obtainment and maintenance of the AHIMA credential (CCS and/or CSS-P, RHIT, or RHIA). Knowledge of ICD-10, ICD-10 PCS, and CPT coding. AAPC credential of CPC also acceptable.
- Experience: Two years of coding and abstracting experience in ICD-9-CM/ICD-10-CM and PCS, DRGs, and CPT including modifiers and APCs.
- Certificates, License, Registrations: CCS, CCS-P, RHIT, or RHIA.
- Knowledge, Skills, and Abilities: Thorough knowledge of PPSs and CAH payment methodology; broad knowledge of pharmacology; knowledge of ancillary testing; anatomy, physiology, and medical terminology; understanding of coding practices; experience with PC, 3M systems; auditing skills; strong process management; good communication skills; basic MS Excel knowledge; compliance with HIPAA and confidentiality.
Physical
Light work: exerting up to 20 pounds occasionally, and/or 10 pounds frequently, or negligible constantly. Walking or standing significantly or sitting constantly, with pushing/pulling controls.
Interpersonal Relationships
- Supervision Received: HIM Manager
- Supervision Exercised: None
- Other: Hospital personnel, medical staff, some public/patients
Exposure To Hazards
Low risk with little or no exposure according to OSHA standards.
Equipment Used
Computer, copier, fax machine, phone, printer.
Additional Details
- Seniority level: Entry level
- Employment type: Full-time
- Job function: Health Care Provider
- Industries: Hospitals and Health Care