Outpatient Coder
Outpatient Coder
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Job Description
Position Purpose
The purpose of this position is to correctly assign ICD10CM diagnostic/procedure PCS codes on clinical encounters in accordance with regulatory and CMS Official Guidelines for coding and reporting to ensure accurate reimbursement.
Nature and Scope
This position may be responsible for identifying appropriate charges based on documentation and coding guidelines. When documentation or a valid order is incomplete vague ambiguous or missing it is the responsibility of incumbent to work in conjunction with HIM staff to utilize the appropriate physician clarification process to obtain additional information that provides a codable sign symptom or diagnosis and/or physician order. Other responsibilities include:
Apply clinical knowledge of disease processes physiology pharmacology and surgical techniques by reviewing and interpreting all clinical documentation included in an inpatient record.
Adherence to Health Information Management (HIM) Coding policies.
Interprets and applies American Hospital Association (AHA) Official Coding Guidelines to articulate and support appropriate principal secondary diagnoses and procedures.
Adherence to The Joint Commission (TJC) and other thirdparty documentation guidelines in an effort to continually improve coding quality and accuracy.
Responsibility for maintaining coding certification and knowledge referencing current.
ICD10CM coding guidelines and regulatory changes.
Contacts the appropriate department or HIM staff member for assistance in obtaining physician clarification of diagnoses.
Participates in performance improvement initiatives as assigned.
Clarify physician documentation by utilizing facility established query process.
Demonstrates knowledge of sequencing diagnoses and procedure codes outlined in the ICD10CM/PCS Official Coding Guidelines Uniform Hospital Discharge Data Set AHA Coding Clinics CMS guidelines and other resources as applicable.
May provide education and support to clinical areas in regard to appropriate documentation and code assignment.
This position must consistently meet or exceed productivity and quality standards as defined by department Leadership.
KNOWLEDGE SKILLS & ABILITIES
- Knowledge of Anatomy and Physiology Pharmacology Disease Pathology and Medical Terminology.
- Knowledge of basic coding conventions and use of coding nomenclature consistent with CMS Official Guidelines for Coding and Reporting ICD10CM and PCS coding.
- Accurate translation of written diagnostic descriptions to appropriately and accurately assign ICD10 CM diagnostic codes and procedural PCS codes to obtain optimal reimbursement from all payer types including Medicare/Medicaid and private insurance payers.
- Ability to navigate the Electronic Medical Record to identify appropriate documentation for coding/billing in support of submitted department charges.
- Knowledge of clinical content standards.
- Utilize critical thinking and problemsolving abilities.
- Ability to work well with others.
- Uphold a strong work ethic characterized by honesty and dependability.
- Demonstrate personal time management skills including organization prioritization and multitasking.
- Adherence to company policies procedures and directives
Employment Type
Full Time
