The Coder is responsible for coding medical records, including all diagnoses and operative and diagnostic procedures in patient medical records, using the current International Classification of Diseases (ICD 10 CM), Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedures Coding System (HCPCS) and entering coded information into an automated grouper system.  Does related work as required.

RESPONSIBILITIES:

• Using the current HCPCS, ICD 10 CM and CPT coding systems, assigns and records an accurate code to all diagnoses, procedures, and operations as documented by the attending physician in the indicated patient's medical record.
• Ensures that all factors necessary for assigning an accurate APC/ APG’s are present, and that all diagnoses are ranked properly.
• Makes appropriate contacts in order to acquire or clarify necessary information.
• Enters final diagnostic code numbers and narrative descriptions of diagnoses and procedures into an automated grouper system.
• Provides information to and responds to inquiries regarding medical documentation, coding,  and APCs/APGs from hospital staff, including utilization and quality assurance staff, patient accounts staff and the Risk Manager.
• Abstracts information from medical records to compile reports and statistical information.
• Enters data such as diagnosis, treatment, admission and discharge dates, length of stay, etc., on hospital-wide or regional automated database.
• Query appropriate provider as necessary regarding documentation of diagnosis and/or procedure.

EXPERIENCE:

• Minimum of one year of experience where the primary function of the position was outpatient medical records coding in or for a hospital.

EDUCATION:

• High school or equivalency diploma, required. An Associate's degree or Bachelor's degree in health information management may be substituted for one year of the required experience.

LICENSES/CERTIFICATIONS:

• Current certification as either a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician Based (CCS-P) through AHIMA, or as a Certified Professional Coder (CPC) through the American Academy of Professional Coders.  

OTHER:

• Thorough knowledge of the current HCPCS, CPT and ICD codes; thorough knowledge of medical terminology, anatomy and physiology;  ability to understand and code medical records; ability to communicate effectively both verbally and in writing; ability to effectively use computer applications or other automated systems such as spreadsheets, word processing, calendar and e-mail for performing work assignments; ability to read, write, speak, understand, and communicate sufficiently to perform the essential duties of the position.