Role Description
This job is responsible for accurately assigning diagnostic (ICD-10-CM), procedure (CPT), and infusion codes to records of emergency department, radiology, and other outpatient encounters and facility settings as assigned, abstracting patient information, and forwarding reports as required. Epic and Solventum encoder experience preferred.
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Maintain established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.
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Possess in-depth knowledge of the conventions, rules, and guidelines of multiple classification systems, including ICD-10 diagnosis and procedures and Current Procedural Terminology (CPT).
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Possess in-depth knowledge of disease process in multiple medical/surgical specialties.
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Review patients' entire current medical records and utilize encoder software and/or code books to assign appropriate diagnosis codes using the International Classification of Diseases, 10th Edition β Clinical Modification (ICD-10-CM) according to predetermined department standards.
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Determine the sequence of diagnoses according to uniform hospital discharge data.
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Review and assign CPT infusion codes following guidelines for infusion administration.
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Review surgical and designated diagnostic procedure documentation to assign appropriate procedure codes using the International Classification of Diseases, 10th Edition, Procedure Coding System (ICD-10_PCS), and Current Procedural Terminology (CPT) using encoder software and/or code books.
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Determine and record other required data items such as attending physician, discharge disposition, number of consultations, referral source, and similar data.
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Query physicians or other providers to obtain clarification and diagnosis information when not recorded on discharge, or if information is incomplete.
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Assist in training hospital personnel in coding procedures.
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Assist in care and maintenance of department equipment and supplies; maintain department records, reports and files as required.
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Participate in educational programs and in-service meetings; attend other meetings as required.
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Retrieve records for closing out each month and make corrections to coded and abstracted information as required.
Qualifications
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At least 1 year hospital experience (Preferred)
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Computer skills (Required)
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High School (Essential)
Requirements
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Certified Coding Specialist-2P-CCS Essential Certification as Certified Coding Specialist (CCS), Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Professional Coder Apprenticeship (CPC-A), Certified Professional Coder-Hospital (CPC-H), Certified Outpatient Coder (COC), Certification as Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) - Time Frame: Upon Hire
Benefits
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Employee portion of medical plan premiums are covered after 3 years.
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4%-10% employee savings plan match based on tenure.
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Paid Parental Leave (up to 12 weeks).
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Caregiver Leave.
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Adoption and surrogacy reimbursement.
Company Description
At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal. Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being. Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.