Clinical Coder II - Acute Care

Overview

Job Summary

Reviews clinical documentation and diagnostic results as appropriate to abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS and CPT 4 codes for reimbursement, external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and other regulatory edits. Code and abstract medical records of low to moderate complexity within the Primary Enterprise acute care facilities.

Essential Functions

• Reviews low to moderate complexity medical records to identify the appropriate principal diagnosis and procedures codes, and all appropriate secondary diagnoses and procedure codes, Present on Admission, Hospital Acquired Conditions and Core Measures Indicators for all diagnosis codes.
• Measures Indicators for all diagnosis codes.
• Facilitates appropriate MS-DRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines.
• Reviews charges including Evaluation and Management levels.
• Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting.
• Abstracts coded data and other pertinent fields in the hospital electronic health record.
• Ensures the accuracy of data input.
• Meets established quality and productivity standards.
• Stays abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.

Physical Requirements

Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.

Education, Experience and Certifications.
High School Diploma or GED and courses in Medical Terminology, Anatomy & Physiology and Pharmacology. College degree preferred. One to two years coding experience in acute care setting preferred. Current RHIT, RHIA, CCS, CPC-H, CPC-A, CIC or CCS-P preferred or obtained within one year plus a passing score on the Coding test.