Coder 2 Hospital

Abstracts all Emergency procedures utilizing the International Classification of Disease Clinical Modifications (ICD-9-CM) system and the Current Procedure Terminology (CPT-4)/HCPCS guidelines for code assignments. Determines and enters charges for ER facility procedures and ER visit levels.

1. Coding and Documentation
   1. Reviews medical record documentation to validate procedure charge indicated by nursing staff and accurately enters charges for procedure selected on chart ticket.
   2. Accurately assigns appropriate procedure codes to emergency room patient records using ICD-9-CM system and CPT-4/HCPCS coding guidelines. Using 3M system abstracts data elements related to procedures performed in the emergency department. Determines the appropriate sequencing of procedures.
   3. Accurately and completely appends modifiers to CPT/HCPCS codes as required.
   4. Accurately and completely posts charges for Drug Administration services (injections and infusions) in compliance with regulatory drug administration guidelines. Units of service are correctly selected.
   5. Assists the Business Office and external agencies in clarification of coding regarding reimbursement issues. Handles all requests in a timely fashion.
2. Quality
   1. Utilizes nurses (Lynx) charge ticket to accurately and efficiently enter charges for evaluation and management (E&M) facility visits.
   2. Consistently places records on pending diagnosis code status to prevent premature bill drop.
   3. Maintains an accuracy rate of not less than 93% based on internal and/or external review and productivity standards engages in problem identification and resolution and assists in data gathering and chart auditing as necessary.
   4. Participates in educational programs (including those provided and required by the Health Information Management Department) in-services and training sessions as required. When appropriate the Coding/Billing Specialist shares his/her own expertise with others in an effort to further the quality of education and personal growth provided to new personnel volunteers and interning students.
3. Collaboration and Partnership
   1. Communicates with the appropriate ER staff members when records with missing information are identified.
   2. Demonstrates competencies in the service to our patients/customers of all ages by obtaining information in terms of customer needs. Speaks in a positive professional manner about co-workers physicians and the facility.
   3. Collaborates with Emergency Room nursing personnel and physicians. Provides education and initiates process improvement opportunities to eliminate discrepancies between charge ticket and Medical Record documentation.
   4. Consults with HIM Coding Supervisor and/or HIM Director in matters of uncertainty regarding coding.
   5. Consults with Revenue Management Department staff regarding chargemaster or charging issues.
4. Other Duties As Assigned
   1. Performs other duties as assigned or requested.

Experience - RHIT/RHIA plus 2 years of acute care coding experience or 4 years acute care coding experience; RHIT/RHIA with ICD-10 curriculum substitutes for all experience; CCS substitutes for 1 year of acute care coding experience; Associates or Bachelors degree in Allied Health or Health Information Systems can substitute for minimum years of experience.

Education - High School diploma or equivalent