The Coding Specialist is responsible for coding patients’ medical charts. The employee must maintain effective communication and good working relationships with the revenue cycle personnel, other departments, Medical Staff and the public, in conjunction with organization policies.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Completes charge sheets for departments that do not electronically generate charges.
Read and interpret health record documentation to identify all diagnosis and procedures that affect the current inpatient, outpatient or clinic encounter.
Assess the adequacy of health record documentation to ensure that it supports all diagnosis and procedures to which codes are assigned.
Accurately identifies and codes the principle and secondary diagnosis for all clinic, outpatient and/or inpatients using ICD-10-CM in accordance with established coding rules and guidelines.
Accurately identifies and codes all ICD-10-CM procedure and CPT procedures in accordance with established coding rules and regulations.
Queries physicians when code assignments are not straight forward or documentation in the records is inadequate or unclear for coding purposes.
Correctly abstracts the required patient data from the record in the computer system in conjunction with code assignments to ensure accurate information for billing and index purposes.
Applies knowledge of anatomy and physiology and medical terminology to assign accurate codes to diagnoses and procedures.
Demonstrates ability to recognize potential coding quality issues from an array of data.
Must be skilled in the use of a PC, encoding and word processing software and transcription equipment.
Serves as a review for accurate and complete assembly and analysis of health records.
Attends continuing education sessions to maintain coding skills.
This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position, as the employee will be required to follow any other job-related instructions and to perform any other job-related duties requested by the supervisor.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Experience coding with ICD-10-CM and CPT classification
Good communication skills both written and verbal, accuracy, attention to detail, basic computer knowledge and typing skills
Must have the ability to work alone without the direct supervision and be able to make independent decision when circumstances warrant such action.
Must posses the ability to seek out and accept new methods and principles and be willing to incorporate them into the department routine.
EDUCATION and/or EXPERIENCE
Successfully completed an approved ICD-10-CM and CPT coding program. Experience using encoder and grouping software and computerized medical information system. Minimum of 3 years coding experience; 5 years of experience preferred.
Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to department managers, patients, and co-workers.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Preferred CCS or CCS-P, RHIT with minimum CCA certification.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; and talk or hear. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is continuously exposed to noise, frequent eyestrain and restricted workstation. The employee is occasionally exposed to fumes or airborne particles.
The duties of this position are representative of OSHA Class III and may be exposed to class III hazards.