Saint Claire Regional Medical Center

Position Summary:

Responsible for accurate inpatient and outpatient coding, analysis and screening of records for billing, research and special studies. Responsible for the timely and accurate coding of administrative and clinical data through the accurate assignment of ICD-10 and/or CPT codes and APC and DRG Assignment and modifiers while complying with the regulations and requirements of the Federal Government, State agencies and the hospital’s policies and procedures. Knowledgeable of medical necessity regulations, NCD and LCD policies. Works closely with Revenue Cycle and HIM members to ensure accuracy of coded data.

Duties/Responsibilities:

• Ensures the correct ICD-10-CM, ICD-10-PCS, APC and DRG Assignment and/or CPT code and modifiers to each diagnosis and procedure are substantiated by documentation contained in the medical record.
• Follows departmental and official ICD-10-CM, ICD-10, -PCS APC Assignment and/or CPT coding guidelines to ensure consistent and accurate coding of diagnostic and procedural data.
• Assists with and requests diagnoses from medical staff when not recorded in medical record or if information is incomplete.
• Corrects edits in conjunction with the patient accounts staff to ensure timely billing of accounts and resolution of potential errors.
• Maintains current knowledge of coding principles and guidelines as coding conventions are updated.
• Adheres to St. Claire HealthCare organizational and department-specific safety, confidentiality, values, policies and standards.
• Ensures records are coded timely and within department defined timelines.

Thoroughly reviews charts to identify all diagnoses/procedures.

• Refers questions to supervisor if there are questions regarding the diagnoses/procedure code.
• Utilizes computerized encoder for assignment of ICD and CPT codes. Refers to coding book as needed for additional information and/or code verification.
• Codes all diagnoses/procedures in accordance to the Health Information Management Coding Manual and AHIMA’s Standards of Ethical Coding.
• Inputs/abstracts, diagnoses/procedure codes into the abstracting and billing systems.
• Meets productivity standards as defined by the department
• Meets quality standards of having 95 percent of principal diagnosis and procedure appropriately/correctly coded for outpatient visits.
• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
• Maintains a good working relationship within the department, other departments and medical staff.
• Must be familiar with the following manuals: Administrative, Health Information Management, HIM Coding.
• Performs other related duties as assigned or requested.

Education:

High School Diploma or equivalent required. Completion of certified ICD 10/CPT coding courses/education or equivalent work experience preferred.

Experience:

Health Information Management experience required. At least one (1) year of abstracting and coding experience in ICD. DRG and CPT, including modifiers and APC assignment.

Licensure/Certification:

Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Registered Health Information Technician (RHIT). Select other AAPC or AHIMA certifications may be considered, based upon needs of the department.

Other:

Knowledge of Coding Systems for proper coding, to include a minimum of ICD-10 and CPT. Knowledge of medical records and the evaluation of medical records. Skill in both verbal and written communications. Skill in the attention to detail to ensure the utmost accuracy for the data entry of medical record information and proper coding. Ability to read, analyze and interpret professional journals, governmental regulations, and coding guidelines. Ability to maintain good working relationships and communication with the medical staff, nursing, administration and other ancillary departments within the hospitals. Ability to accurately perform multiple tasks and observe strict deadlines.

Physical/Work Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform 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 regularly required to sit and use hands to finger, handle or feel. The employee is required to communicate effectively. Specific vision abilities required by this job include close vision for reading and computer work. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move more than 50 pounds.

The work environment described here is representative of those that must be met by an employee to successfully perform 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 works in an area with good lighting and climate control. The noise level in the work environment is usually moderate.