Outpatient Coder

AAPC; Town of Warwick (NY); On-site; USD 65,000 - 85,000; Full time

Job summary

AAPC is seeking a skilled Medical Coder to accurately code outpatient medical records using ICD-10-CM, CPT and HCPCS, and to enter data into the automated grouper system. The role requires attention to detail and strong knowledge of coding standards.

The successful candidate will assign codes for diagnoses and procedures, verify APC/APG rankings, and work with hospital staff to clarify documentation. Proficiency with medical terminology and healthcare software is essential for accurate coding

Qualifications

• Minimum of one year of outpatient medical records coding experience.
• Certification as CCS/CCS-P or CPC.
• Proficiency with HCPCS, CPT and ICD coding systems.

Responsibilities

• Code medical records using ICD-10-CM, CPT, HCPCS and enter data into the grouper system.
• Assign accurate codes for diagnoses and procedures documented by physicians.
• Ensure correct APC/APG ranking and code queries when needed.
• Communicate with hospital staff to clarify documentation.
• Abstract information from records and input into hospital databases.
• Query providers to clarify documentation and coding details.

Skills

Medical terminology

Anatomy & physiology

Coding accuracy

Healthcare software

Education

High school diploma or GED

Associate's degree in Health Information Management

Bachelor's degree in Health Information Management

Job description

Responsibilities

The Coder is responsible for coding medical records, including all diagnoses and operative and diagnostic procedures in patient medical records, using the current International Classification of Diseases ("ICD 10 CM"), Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedures Coding System (HCPCS) and entering coded information into an automated grouper system. Does related work as required.

• Using the current HCPCS, ICD 10 CM and CPT coding systems, assigns and records an accurate code to all diagnoses, procedures, and operations as documented by the attending physician in the indicated patient's medical record.
• Ensures that all factors necessary for assigning an accurate APC/ APG's are present, and that all diagnoses are ranked properly.
• Makes appropriate contacts in order to acquire or clarify necessary information.
• Enters final diagnostic code numbers and narrative descriptions of diagnoses and procedures into an automated grouper system.
• Provides information to and responds to inquiries regarding medical documentation, coding, and APCs/APGs from hospital staff, including utilization and quality assurance staff, patient accounts staff and the Risk Manager.
• Abstracts information from medical records to compile reports and statistical information.
• Enters data such as diagnosis, treatment, admission and discharge dates, length of stay, etc., on hospital-wide or regional automated database.
• Query appropriate provider as necessary regarding documentation of diagnosis and/or procedure.

Qualifications/Requirements

Experience

Minimum of one year of experience where the primary function of the position was outpatient medical records coding in or for a hospital.

Education

High school or equivalency diploma, required. An Associate's degree or Bachelor's degree in health information management may be substituted for one year of the required experience.

Licenses / Certifications

Current certification as either a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician Based (CCS-P) through AHIMA, or as a Certified Professional Coder (CPC) through the American Academy of Professional Coders.

Other

Thorough knowledge of the current HCPCS, CPT and ICD codes; thorough knowledge of medical terminology, anatomy and physiology; ability to understand and code medical records; ability to communicate effectively both verbally and in writing; ability to effectively use computer applications or other automated systems such as spreadsheets, word processing, calendar and e-mail for performing work assignments; ability to read, write, speak, understand, and communicate sufficiently to perform the essential duties of the position.

Special Requirements

N/A