Role Description
Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be utilized for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
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Reviews the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses, and procedures performed.
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Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes, and other ancillary services treatment records.
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Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes as required.
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Using the Encoder software program, determines the codes for all diagnoses and procedures.
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Determines their sequencing to legally maximize reimbursement.
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Assigns the appropriate DRG.
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Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant, or other standard coding guidelines.
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Queries physicians as needed to clarify documentation within the patientβs record.
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Communicates to Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc. documented within patient records.
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Provides and arranges training for coding professionals in the use of coding guidelines and practices, proper documentation techniques, medical terminology, and disease processes.
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Completes coding quality audit reviews to ensure all available cases were coded and entered into the hospital and professional computer system correctly.
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Develops coding policy and procedure or position papers related to correct coding for new or emerging technology services provided by clinical staff.
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Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures.
Qualifications
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Minimum of One relevant certification from AHIMA or AAPC is required upon hire.
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Acceptable certifications include:
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AHIMA (American Health Information Management Association):
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Certified Coding Specialist (CCS)
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Certified Coding Specialist β Physician-based (CCS-P)
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Registered Health Information Technician (RHIT)
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Registered Health Information Administrator (RHIA)
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Certified Coding Associate (CCA) β Candidates with only a CCA are required to obtain a CCS, RHIT, or RHIA within 12 months of hire.
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All certifications are acceptable from AAPC (American Academy of Professional Coders) except:
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Scribe, Documentation, Instructor, and International Credentials
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Certified Professional Biller (CPB)
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Revenue Cycle Management Specialist (RCMS)
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Certified Value-Based Administrator (CVBA)
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Certified Physician Practice Manager (CPPM)
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Certified Professional Compliance Officer (CPCO)
Requirements
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High School Diploma or Equivalent (GED) - Required
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Minimum of 7 years Relevant experience - Required
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Relevant coding certification - Default Issuing Body
Benefits
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Healthcare benefits for full-time and part-time positions from day one, including vision, dental, and domestic partners.
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Encouragement of an atmosphere of collaboration, cooperation, and collegiality.
Company Description
Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.