MUST BE AHIMA CERTIFIED

MUST PASS CODER II TEST WITH MIN SCORE 75%



As needed, Coders II may assist and be a resource for data integrity for other employees who need clarification and assistance in coding.
Work is performed in accordance with the rules, regulations and coding conventions as established by the American Hospital Association (Coding Clinic), ICD9, CMS, OSHPD and Clients organizational/institutional coding guidelines.

Education/License/Certification:
This position requires a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA). Completion of classes in medical terminology, anatomy and physiology, ICD-9 and CPT coding conventions, and disease process from an accredited program.
Must have high school diploma or GED.

Qualifications:
Must have three years of continuous hospital experience in coding.
Demonstrated ability to understand the clinical content of a health record.
Demonstrated ability to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses.
Basic PC skills. Must maintain current coding credential as for mentioned. Will abide by the AHIMA coding code of ethics.

Duties:

Review medical records to identify diagnoses/procedures.
Under general supervision, organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements. Demonstrates knowledge of all procedures concerning the sequencing of diagnoses, procedures as outlined in but not limited to ICD-9-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding outpatient encounter or inpatient discharge data.
The above duty statements are intended to describe the general nature and level of work being performed by individuals assigned to positions in this classification and, as such, are not intended to be construed as an exhaustive list of duties, responsibilities and skills required of every position so classified.

Assigns Codes:
Under direct supervision: Codes all diagnostic and operative information from the medical record using ICD-9-CM , CPT, HCPCS level 2 coding classification systems.
Selects the DRG for each inpatient case. Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.
Verifies and abstracts all medical data from the record to complete a data abstract on hospital encounters.
Corrects data as appropriate.
Ensures that all data abstracted and/or coded are consistent with guidelines outlined by JCAHO, OSHPD and CMS, regional and local policy.

Completion of Medical Records:
Under general supervision, interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
Enters patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract or encounter data prior to transmitting case.
Ensures timely record availability by meeting coding and abstracting productivity / quality standards established for Coders I.
Participates in medical record documentation auditing to monitor physician compliance with regulatory requirements i.e., Physician Review Project.

Other duties: Answers the telephone promptly and identifies themselves and the department. Acts as a resource person to other hospital departments regarding coding questions and issues. Other duties as assigned by supervisors.