Coder III, Coding

DHR Health - US:TX:McAllen - Days

Summary

POSITION SUMMARY

The Inpatient coder reviews and analyzes documentation in the medical record for inpatient visits to ensure accuracy of diagnosis and procedure codes. Coder finalizes the coding and abstracting of the medical record according to ICD-10-CM/PCS, CPT, and HCPCS coding conventions and guidelines supported by the clinical documentation in the medical record. Coder analyzes diagnosis and procedure codes concurrently assigned by Clinical Documentation Specialists. The Inpatient Coder assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Sequence the diagnoses and procedures using official coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges. Resolve Inpatient billing edits. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).

POSITION EDUCATION/ QUALIFICATIONS­

• RHIA, RHIT, CCS or CIC required. Three to five years hospital experience required.

JOB KNOWLEDGE/EXPERIENCE­

• Experience and/or advanced training in medical coding (MS/APR DRG’s, ICD-10-CM, CPT, HCPCS, ect...),
• Must have extensive knowledge of medical terminology, anatomy and physiology, knowledge of pharmacology and all major diseases
• Requires reasoning ability and good independent judgment.
• Critical thinking skills are a must. Must have strong interpersonal skills and the ability to multi-task
• 3M CRS software experienced preferred
• Requires good communication and organizational skills
• Must have an understanding of laws and ethics related to health insurance, medical billing and the health insurance
• Portability and Accountability Act (HIPPA)
• Requires working with minimal to moderate interruptions.
• Must complete CE hours annually, according to certification requirements Professional coding and billing experience a plus

Responsibilities

POSITION RESPONSIBILITIES

• 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 all inpatient diagnoses and procedures according to ICD-10-CM/PCS, CPT and HCPCS coding conventions and guidelines.
• Follows the AHIMA Standards of Ethical Coding to adhere to Coding Compliance guidelines.
• References ICD-10-CM/PCS, CPT, and HCPCS Level II code books as needed.
• Accurately attach HCPCS level I and level II modifiers when appropriate
• Utilizes 3M Coding references daily for final coding
• Utilizes computerized 3M Coding Software.
• Meets quality standards of having 95% of charts coded accurately.
• Maintains a good working relationship within the department, other departments and medical staff
• Codes all available records in a timely manner.
• Queries physicians for clarification when ambiguous or incomplete information is present.
• Communicates with Coding Manager to solve problems and to clarify coding issues.
• Attends workshops, seminars or conferences that pertain to position and that fulfill CE hour requirements
• Reviews Coding Clinic updates and continuing education periodicals in a timely manner
• Maintain ongoing education to stay abreast of updates in coding conventions and practices
• Assists the business office with clearing reimbursement and denial issues
• Clears Aeos in a timely manner
• Notify HIM staff of incomplete or un-scanned records through the tickler system
• Adheres to the Health Information Management Policies and Procedures for coding.
• Adheres to the Coding Compliance Plan.
• In case of any inaccuracies or discrepancies in the medical record, then it is his or her responsibility to report the matter to the appropriate department so that the necessary corrections can be made
• Maintains confidentiality and safeguards all patient related information
• Ability to train and mentor junior staff members
• Performs Peer review and internal audits
• Performs other duties as assigned

Other information:

LINES OF REPSONSIBILITIES:

(Chain-of-command)

• (Director)

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. Essential Duties: 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

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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. 3

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. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

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. 2

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. 3

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: ________________________.