POSITION SUMMARY

The responsibility of the Coding Specialist Certified is to search a patient's entire medical record to ensure comprehensive coding and abstracting utilizing the coding rules, principles and ethics under the supervision of the Coding Supervisor and Manager, Health Information Management. With quality and reimbursement contingent upon coding, it is the responsibility of the Medical Center Coding Specialist Certified to have knowledge of DRG methodology, ICD-10, CPT-4 and APC coding rules and principles.

MINIMUM REQUIREMENTS

Education:

1. Graduate of an approved Health Information Management Technology program, preferred, with Registered Health Information Technician (RHIT) credentials, Certified Coding Specialist (CCS) or other relevant credential, relevant experience, required or eligible.
2. As a secondary preference will also consider graduates of Medical Office Specialist program with current, acute care experience with ICD-10, CPT, DRG coding rules and methodologies with Certified Coding Specialist (CCS) or other relevant credential, relevant experience, required or eligible.

Experience:

1. Current, acute care experience with ICD-10, CPT, DRG, APC coding rules and methodologies preferred.

Knowledge, Skills, Abilities:

1. Demonstrates knowledge of diagnostic and procedural terminology, medical terminology and disease processes (anatomy and physiology).
2. Self-motivated individual with personal integrity to organize work and work independently.
3. Typing skills with basic knowledge of computer operations.
4. Communication skills necessary to approach the medical staff, hospital personnel, ancillary department etc. for any clarifications regarding record questions or problems utilizing coding rules and principles.

License/Certification/Registration:

1. Maintains Registered Health Information Technician (RHIT) credentials and/or Certified Coding Specialist (CCS) or other relevant credential by completing continuing education requirements.

SUPERVISION RECEIVED

Receives minimal supervision from the Supervisor, HIM Coding.  Must be able to work independently.

SUPERVISION GIVEN

None

ESSENTIAL FUNCTIONS

1. Reviews the medical record for diagnoses and procedures performed.
   1. Analyzes and searches the documentation listed in the entire medical record for all documented clinical information (diagnoses and procedures) in accordance with established procedures, daily, and trained in a minimum of 3 out of the 4 following areas:
      1. Inpatient records
      2. Outpatient records
      3. Emergency Room records
      4. Clinical /Diagnostic records
   2. Identifies and sequences principal diagnosis, secondary diagnoses, principal procedures, complications and comorbid conditions, for optimal reimbursement, utilizing proper coding practices, on a daily basis.
2. Selects ICD 10-, CPT-4, DRG code assignments.
   1. Assigns proper ICD-10, CPT-4, DRG codes for all diagnoses, procedures, complications, and comorbid conditions during the course of hospitalization after researching the entire record, maintaining a 95% accuracy rate, on a daily basis.
3. Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.
   1. Data enters accurate ICD-10 and CPT-4 codes, physician related and clinical information, and demographic information into computerized coding/abstracting system, in accordance with established procedures, maintaining a 95% accuracy rate, on a daily basis.
   2. Assigns DRG and electronically releases accounts for generation of a patient bill after physician completion, as required.
   3. Processes and follows through with clinical codes and diagnostic information as records are returned by physicians, in accordance with established procedures, on a daily basis.
   4. Enters charges on Emergency Department medical record based on procedure coding, according to rules applied by each payer.
   5. May work with the Clinical Documentation Specialists.
   6. May complete Radiology and/or Medical Necessity worklists.
   7. Meets standard of performance as follows:
      1. Trainee: Average inpatient: 45-60 minutes per chart. Average outpatient: 15-20 minutes per chart. Average ED: 15 minutes per chart. Average clinic: 3-4 minutes per chart.
      2. Experienced: Average inpatient: 30 minutes per chart. Average outpatient: 12 minutes per chart. Average ED: 8-9 minutes per chart. Average clinic: 2-3 minutes per chart.
4. Meets Performance Standards for Insurance Billing:
   1. Coordinates outpatient coding for Medicare, Blue Cross, Medical Assistance, HMO’s, and Commercial Insurance accounts.
   2. Reviews registration information at the time of coding for accuracy.
   3. Enters coding into the system in preparation for electronic and hardcopy claims submissions following HIPAA guidelines.
5. Processes incomplete records.
   1. Forwards incomplete and/or invalid records to physician, and/or clarifies concerns regarding the record with the physician, as required.
   2. Assists in chart completion utilizing computerized system and following established departmental procedures.
6. Maintains timely completion of records.
   1. Expedites the completion of the abstracting procedure to generate the patient bill in a timely manner, in accordance with established procedures, on a daily basis.
   2. Assists with facilitation of timely and accurate chart completion and processing.
   3. Performs coding/abstracting utilizing electronic records according to procedure.
7. Remains current in coding rules and practices. Reviews current literature and acquires reference material to enhance knowledge regarding diagnostic and procedural terminology.  Remains current in coding practices through reading, attendance of in-service programs, and designated continuing educational programs, as required for up to date practices.
8. Participates as a team member to the organization.
   1. Maintains liaison with medical staff, hospital personnel, patients, other hospitals, and clinics, as required.
   2. Assists with orientation and ongoing training of new/other employees to specific coding job functions at a level that employee can accomplish, as assigned.
9. Practices excellent communication skills.
   1. Receives and records initial contacts on the telephone or via computer; courteously assists callers; answers incoming telephone calls, takes message, provides information or routes calls to appropriate individual; answers incoming emails, provides information or directs to appropriate office or individual.

NON-ESSENTIAL FUNCTIONS

1. Performs related and miscellaneous duties as assigned.
   1. Accepts additional assignments as required from supervisory personnel meeting any specific time frame indicated.
   2. Assists supervisory personnel in any task oriented job function to maintain effective, timely chart flow and expedite cash flow, as needed.
   3. Assists with proficiency/competency reviews as assigned.