To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Performs a variety of coding activities involving the simple to moderately complex records including but not limited to Same Day Surgical accounts, observation visits and those cases coded by a Coder 1 as a mechanism for indexing medical information; which is used for completion of statistics for hospital, regional and government planning, accurate hospital reimbursement, research, utilization and appropriateness of care.
Responsibilities: 1. Analyzes and codes patient encounters in a timely and accurate manner to ensure quality data and timely billing. 1.1 Completes assigned work ensuring department benchmarks are met or exceeded consistently in accordance with current industry standards and use of current technologies. 1.2 Ensures all available records are coded to meet OP coding minimum days/CFB. 1.3 Monitors and works "Bill Edit Report" on a daily basis in order to maintain the departmental goal. 1.4 Analyzes and assigns all YNHHS codes and diagnoses in accordance with national coding and departmental guidelines. 1.5 Assigns ICD-10 and CPT codes and ensures consistency between procedures charged for, using the charge master and clinical evidence within the documentation achieving an accuracy rate of 95% or greater. 1.6 Assigns correct surgeon and date of procedures with an accuracy rate of 95% or greater including correct sequencing of codes. 1.7 Independently researches all coding problems, using all resources including but not limited to Encoder/CAC prior to seeking help from the supervisor or coding specialist. 1.8 Reviews and analyzes any initial coding edits, such as CCI/OCE. 2. Maintains professional skills and remains engaged in the goals and vision of the organization to ensure the department functions efficiently and accurately with integrity. 2.1 Actively participates in staff meetings and offers constructive suggestions for improving the process. 2.2 Identifies and reports all procedures and findings that are not accurate. 2.3 Reviews all memos, emails and policy updates as they are distributed to ensure current coding and billing procedures are followed. 2.4 Participates in career development activities by utilizing American Coding School, reading journals and coding articles and attending coding educational in-services and webinars. 2.5 Complies with all aspects of telecommuting agreement and participates in all mandatory training and/or staff meetings. Reports to work on-site as requested. 2.6 During periods of heavy workload, will provide assistance to other work areas as needed and will exercise good judgment and demonstrate flexibility. 2.7 Maintains skills with ICD-10-CM, ICD-10-PCS and CPT-4 through the use of Coding Books and/or utilizes Encoder/CAC to ensure current resources are referenced to assure accurate and up-to-date code assignments. 2.8 Assist in cross training of staff as needed and requested by coding leadership. 2.9 Review and respond to quality and compliance audits within the required response period using the assigned documentation format.
High school graduate with additional training in ICD-10, CPT-4 and evaluation and management coding. CCS, CCS-P, CPC, or COC certification required.
Minimum of two (2) years'' experience coding outpatient medical records using ICD-10-CM, ICD-10-PCS, CPT-4 and E&M classification systems required. Proficient with ICD-10-PCS coding.
Certified Coder: CPC, COC, CCS or other applicable coding certification through the AAPC and/or AHIMA required.
In-depth knowledge of medical terminology, anatomy and physiology, and disease process. Comprehensive understanding in use of ICD-10-CM, ICD-10-PCS and CPT-4, and E&M coding systems, as well as understanding of APCs. Good oral and written communication skills. Ability to exercise good judgment, independent logic, intermediate to advanced level computer data entry (numerical and alphabetical) skills. Computer system experience including familiarity with encoder systems.
Responsible for accurate selection of diagnoses, procedures and appropriate codes, timely coding, and subsequent entry of data into hospital billing system; maintenance of 95% accuracy rate or greater.
Exercises independent judgment in determining appropriate diagnostic and procedure data from all types of medical record documentation and in contacting physicians.