The Coder I interprets medical documentation to assign the uniform classification system to meet mandated requirements such as Diagnosis Related Grouping (DRG) and Ambulatory Patient Group (APG) assignments under Medicare. The Coder abides by the Official Guidelines for Coding and Reporting. Assignments shall meet with medical staff approval.  Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values.

Education:

• High School Diploma/Equivalent required

Licensure/Certification/Registry:

• Certified Coding Associate (CCA), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA), successful completion of a coding program, or six months coding, health information, or relevant experience required.
• Certification must be current.

Experience:

• Previous coding, health information management, physician medical office, registration, or billing experience preferred.

Other Knowledge/Skills/Abilities:

• Demonstrates excellent knowledge of proper use of ICD-9, ICD-10-CM, ICD-10-PCS, and CPT-4 coding guidelines and principles, and AHA Coding Clinics.
• Knowledge of Revenue Cycle, Utilization Review, and Billing process desired.
• Demonstrates excellent interpersonal and communication skills.
• Demonstrates ability to work independently.
• Word processing/computer application experience and knowledge desired.  Coding software familiarity preferred.

1. Reviews medical records and accurately code the principal and all secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, and/or CPT coding conventions; sequence the diagnoses and procedures using coding guidelines; abstract and compile data from medical records to assign the most appropriate codes for optimal reimbursement.

2. Assists in the charge capture process to ensure the capture of technical and professional charges related to the healthcare services provided. Enter charges based on department documentation.  Responsible for appropriate application of charges for services provided in the Emergency Department by the physician and for resources utilized by the facility including professional fee, facility fee, procedure and supplies.

3. Performs coding of inpatient/observation accounts, as assigned by supervisor/manager, performs coding analysis on inpatient/observation accounts utilizing 3M and /or other coding products. Prepares coding summaries.  Abstracts all coded records in coding system per procedure.  Assists with post bill audit as directed by supervisor/manager.  Ensure the MS-DRG assignment is accurate.

4. Performs coding of outpatient diagnostic accounts- as assigned performs coding analysis on all outpatient diagnostic accounts utilizing 3M and/or other coding products. Abstracts all coded accounts in coding system per procedure.  Ensure ambulatory payment classification (APC) assignment is accurate.

5. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:

• • SAFETY: Prevent Harm - I put safety first in everything I do.  I take action to ensure the safety of others.

• • COURTESY: Serve Others - I treat others with dignity and respect.  I project a professional image and positive attitude.

• • QUALITY: Improve Outcomes - I continually advance my knowledge, skills and performance.  I work with others to achieve superior results.

• • EFFICIENCY: Reduce Waste - I use time and resources wisely.  I prevent defects and delays.

6. Maintains competency with coding changes. Participates in required continuing education and compliance training programs to maintain an understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques to support the effective application of ICD-10-CM, ICD-10-PCS and CPT coding guidelines for outpatient diagnoses and procedures.  Staff will maintain up-to-date knowledge of medical records practices, standards, regulations, The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), Federal Intermediary (FI) and other related organizations. 

7. Ensures compliance with all current Abraham Lincoln Memorial Hospital and department policies and procedures.

8. Ensures accurate and timely coding of records, within organizational and departmental guidelines. Ensure patient confidentiality and information security according to laws and regulations governing privacy and security.

9. Communicates with Patient Accounts to resolve billing/coding matters. Demonstrates ability to cooperate with Abraham Lincoln Memorial Hospital management personnel, physicians and other persons contacted during the working day.  Works directly with physician and Allied Medical Staff to clarify coding issues.  Utilizes physician documentation query form effectively. 

10. Enters and retrieves patient medical data from computer terminal updating entries as necessary; audit medical record for accuracy and completeness, note deficiencies and refer for appropriate follow up and completion.

11. Participates in routine coding meeting with Coding Supervisor and other meetings at determined appropriate.

12. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.