Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM codes for billing, internal and external reporting, research, and regulatory compliance. Accurately code outpatient conditions and procedures as documented in the ICD-10-CM Official Guidelines for Coding and Reporting. Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors. Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for outpatient encounters. Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures. Utilizes technical coding principals and APC reimbursement expertise to assign appropriate ICD-10-CM diagnoses and procedures. Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines. POSITION EDUCATION/ QUALIFICATIONS : CCS-P, CCA, CPC, COC, CIRCC, CTR, CIC, CPC-P, CPC-H, Specialty, or Medical coding certification program preferred JOB KNOWLEDGE/EXPERIENCE :
Experience and/or training in medical coding, medical terminology and anatomy and physiology required.
Requires reasoning ability and good independent judgment
Ability to perform productive research quickly
Requires working with minimal interruptions
Must have an understanding of laws and ethics related to health insurance, medical billing and Health insurance Portability and Accountability Act (HIPPA) Computer and coding software experience required, 3M encoder preferred

POSITION RESPONSIBILITES: Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices Accurately Codes outpatient procedures according to most current ICD-10
CM, CPT and APC guidelines Utilizes computerized 3M Coding Software Ability to code outpatient record types such as: EMR, Radiology, Series, RMF Clinics, ect… Ability to accurately attach HCPCS Level I and Level II modifiers for billing purposes Must meet volume requirements of 120
150 accounts coded daily Meets quality standards of having 95% of charts coded accurately Must take initiative in researching to further his/her own knowledge in coding Must research 3M Coding references for final coding Must be able to validate CPT and procedure description Must be able to identify medical abbreviations, terms and their meanings Must be able to multitask Maintains a good working relationship within the department, other departments, and medical staff Codes all available records in a timely a manner Meets productivity standards set forth by the coding manager Communicates with Coding Manager to solve problems and to clarify coding issues Assist the business office with clearing reimbursement and denial issues Clears Aeos in a timely manner Communicates with other departments to obtain pertinent information related to Attends workshops, seminars or conferences that pertain to position and that fulfill CE hour requirements References updated ICD-10
CM/PCS, CPT, and HCPCS Level II electronic code book references as needed Reviews Coding Clinic updates and continuing education periodicals in a timely manner Adheres to the Health Information Management Policies and Procedures for Coding Adheres to the Coding Compliance Plan Follows the AHIMA Standards of Ethical Coding Maintains confidentiality and safeguards all patient related information. Performs other duties as assigned Other information: LINES OF REPSONSIBILITES : (Chain-of-command) 1. Coding Supervisor → 2. Coding Director → 3. Executive Physician /VP of Medical Affairs CUSTOMER SERVICE: Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service. AGE SPECIFIC : Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age. AMERICANS WITH DISABILITIES ACT: (ADA) : A.

Indicated by bold print within performance standards, preceding individual numbered criteria. The following table provides physical requirements that will be associated with, but not limited to, this position:
Light/moderate lifting up to 20 lbs, from the floor to shoulder height.
Yes
Kneeling
Yes
Must be able to assist other employees with lifting more than 20 lbs.
Yes
Walking
Yes
Light/moderate carrying up to 20 lbs.
Yes
Standing/Squatting
Yes
Straight pulling
Yes
Sitting
Yes
Pulling hand over hand
Yes
Pushing
Yes
Repeated bending
Yes
Stooping/Bending
Yes
Reaching above shoulder
Yes
Climbing Stairs
Yes
Simple grasping
Yes
Climbing Ladders
No
Dual simultaneous grasping
Yes
Depth Perceptions needed
Yes
Ability to see
Yes
Identify Colors
Yes
Operating office equipment
Yes
Twisting
Yes
Operating mechanical equipment
Yes
Crawling
No
Ability to read and write
Yes
Ability to Count
Yes
Ability to hear verbal communication without aid
Yes
Operating Personal Vehicle
Yes
Ability to comprehend written/verbal communication
Yes
Other: Ability to deal with stress
Yes
OSHA Category
III
B. Working Conditions : The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents. C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way. D. Aptitudes : HIGH 1 2 3 4 5 6 LOW Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 1 Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 1 Numerical: Ability to perform arithmetic operations quickly and accurately. 3 Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 3 Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3 Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2 Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 4 Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3 Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3 Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3 Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3 I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform. If applicable ____________ certification will be completed within _________ time frame of hire/transfer date. Employee Signature: ________________________________ Date: ____________________ Transfer/Hire Date Effective: ________________________.

Coder I, Coding

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