Health Information Coder

POSITION SUMMARY: 

Under the direction of the Business Office Manager, the Health Information Coder reviews, analyzes and assures the final diagnoses and procedures as stated by the providers are valid and complete.  Accurately codes procedures for providers to ensure proper reimbursement.   Provides education to the providers to ensure proper completion of Electronic Health Records and proper assignment of ICD-10-CM and CPT codes.  

 

 

 PRINCIPAL JOB DUTIES AND RESPONSIBILITIES:

 

Supplies correct CPT code on all procedures and services performed.
 

Audits medical records to ensure proper coding completed and to ensure compliance with federal and state regulatory bodies.
 

Accurately follows coding guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
 

Determines the final diagnoses and procedures stated by the physician or other health care providers are valid and complete.
 

Qualitative Analysis – Evaluates the record for documentation consistency and adequacy.   Ensures that the final diagnosis accurately reflects the care and treatment rendered.  
 

Analyzes provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.
 

Resolve or clarify codes or diagnosis with conflicting, missing, or unclear information by consulting with physicians, providers or others.
 

Stay abreast of industry changes and updates and effectively applies.   
 

Coding productivity and accuracy per department standards.
 

Other duties as assigned.
 

Participate in performance improvement and continuous quality improvement activities.
 

Complete continued education/training requirements.
 

Adheres to all HR and hospital policies and procedures.
 

 

 

EMPLOYMENT STANDARDS, EDUCATION AND STANDARDS

 

High School diploma or GED required.  Associates Degree preferred.  AAPC or AHIMA credentialing is required.  Excellent interpersonal skills.  Knowledge of medical records, EHR required.  Knowledge of official coding conventions and rules established by the American Medical Association (AMA), and the Center for Medicare and Medicaid Services (CMS) for assignment of diagnostic and procedural codes.

 

Must have good math skills and effective communication skills.  Perform coding work requiring independent judgment with speed and accuracy.   Communicating clearly and concisely, orally and in writing.  Confidentiality.  Ability to work independently and to accomplish assigned work in a timely manner.   

 

Understanding and carrying out verbal and written directions.  Work independently in the absence of supervision.  Working knowledge of all equipment, basic computer skills and demonstrate skill in employee relations and problem solving.   Able to interact with wide variety of individuals and handle several complex situations simultaneously.   Evidence of leadership, integrity and initiative.

 

 

WORKING CONDITIONS:

Requires prolonged sitting or standing. Requires ability to distinguish letters, numbers and symbols.   Requires awareness of personal limitations and flexibility.  Some emotional stress resulting from diversity and intensity of patients and staff.   Utilizes good hearing, vocal and visual skills.    Requires frequent lifting up to 20 pounds and occasional lifting up to 50 pounds.  Occasionally requires bending and stretching.  Pushing and pulling. The incumbent works under good conditions in a clean environment.   May be exposed to communicable diseases.   No supervisory responsibilities.  

 

 

EQUIPMENT:

Computer and Printer

Copy Machine

Fax Machine

Telephone

 

 

RESPONSIBILITY FOR CONFIDENTIAL INFORMATION:

This position could have access to patient confidential records and must comply with HIPAA regulations as well as Hospital and Clinic Compliance Policies.