POSITION PURPOSE: Two to three sentences describing the overall purpose of the position.
Reads patient records. In accordance with Governmental, third party payer, and facility rules and regulations, accurately assigns and sequences ICD-10-CM diagnosis, ICD-10-PCS procedural codes and/or CPT E&M and procedural codes to inpatient and outpatient records for use in reimbursement and data collection.
ESSENTIAL JOB FUNCTIONS: Maximum of ten functions in order of percentage of time spent on functions from longest to shortest; do not list anything that does not represent at least 10% of the jobâ??s time. Please include supervisory responsibilities.
1. Attention to Detail: Verifies patient information to identify any documentation vs. report discrepancies and to ensure codes and other abstracted data are accurately applied to appropriate patientâ??s account/encounter.
2. Coding and Abstracting: Primarily codes outpatient and/or professional encounters. Applies codes to conditions and procedures documented in and abstracts data from medical records to provide information for financial reimbursement and data collection, converts interpreted data into appropriate code numbers. Assesses documentation and/or queries physician for additional information when indicated to clarify or provide specificity to a diagnosis, symptom, or reason for an outpatient service. Proficient in accessing and understanding local and national coverage determinations (LCDs/NCDs).
3. Quality Control: Recognizes and reports unusual circumstances and/or information with possible risk factors to appropriate risk management and HIM Director and reports problems, errors, and discrepancies in dictation and patient records to HIM Director. While reviewing the record for coding purposes, serves as quality reviewer of scanned documents. Identifies mis-scans and poorly scanned documents and reports them to HIM Director.
4. Quality/Quantity: Meets coding quality and quantity expectations. Strives to maintain coding within one business day of the account populating the coding queue. Accommodates a varied work schedule including rotating weekend coverage to achieve the one day turnaround.
5. Collaboration: Collaborates with others in the organization including the Quality Department, Medical Staff, other clinicians, and physician office staffs; and with Patient Financial Services to ensure the codes submitted for claims are supported by the documentation in the record. When querying clinical staff, uses appropriate querying techniques to avoid leading the clinician and follows up to ensure queried accounts are dropped within 10 days of the query. As needed, involves the HIM Director or Coding Supervisor. Promptly addresses ticklers (edits) and questions from Patient Financial Services within one business day. May participate in various hospital/physician committees as appropriate and prepare and provide provider inservices.
6. Constant Learner: Attends all required in-services and coder meetings. Identifies and attends training and educational programs conducive to professional growth. Utilizes current literature and workshops attended to the benefit of VVMC. New ideas, policies, regulations, and philosophies are adapted to current policies and procedures appropriately.
7. VVMC Supporter: Supports the philosophy, objectives, and goals of VVMC and the HIM department by volunteering in various capacities without compromising performance expectations. Role models the principles of a Just Culture.
8. HIM Department Supporter: Contributes to the efficiency of the HIM department. Routinely volunteers to assist others when his/her work is completed.
9. Ethics: Routinely abides by standards of professional and ethical conduct as defined by CMS, AHIMA, and the professional organization from which the incumbent is certified and/or credentialed.1
10. Compliance: Understands and complies with policies and procedures related to medicolegal matters including confidentiality, amendment of medical records, release of information, patient rights, medical records as legal evidence, informed consent, etc. Is knowledgeable of and complies with VVMC HIPAA, Safety and Compliance Program Policies and Procedures.
11. Other Duties: Perform other duties as assigned.
This description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Meets productivity requirements: All productivity requirements include accessing records on-line, abstracting, maintaining logs, handling paper records as needed, keeping current with office email, preparing queries and/or following up with physicians for clarification of documentation and/or additional conditions to possibly support medical necessity, and running reports required to perform oneâ??s work)
Ancillary Testing: 20/productive paid hour Includes ICD-10 diagnosis code assignmentTherapy or Occupational Health: 12/productive paid hour Includes ICD-10 diagnosis and applicable CPT code assignmentAmbulatory Surgery: 4/productive paid hourIncludes ICD-10 diagnosis and CPT procedure code assignment, with modifiers, if applicable.ER/Urgent Care Encounters: 6/productive paid hourIncludes Physician E&M, hospital ICD-10 diagnoses and CPT code assignment, with modifiers, if applicableObservations: 3/productive paid hour Includes ICD-10 diagnoses and CPT code assignment, with modifiers, if applicableInpatients (Acute): 2/productive paid hourIncludes ICD and CPT code assignment, validating that outpatient services comply with 3-day rule, POA code assignment and validation of the discharge dispositionProFee Encounters: 12 (medical); 10 (surgical)/productive paid hour Includes E&M, ICD-10 diagnosis, procedure CPTs and, if appropriate modifiers?
Competently codes three or more record types: Observation, Outpatient Surgery, Ancillary, Clinic, ED/Urgent Care, Therapy or codes ProFee with diagnoses and procedures for three or more specialties.
Routinely achieves or exceeds quality expectations of 90% accuracy for coding and 97% for abstracting.
Must achieve quality and productivity expectations within 90 days of employment.
Education: High school graduate with courses in anatomy and medical terminology required; Courses in physiology and pharmacology preferred. Graduate of a coding certificate program, associate or bachelor degree in health information technology or other allied health field.
Has 2 or more yearsâ?? ProFee production coding experience or 2 or more years of hospital outpatient coding experience. Is credentialed/certified.
Competently codes three or more outpatient record types or five or more physician specialties including surgical and medical specialties.
Routinely achieves or exceeds quality and quantity expectations for coding and abstracting. Quality and productivity performance is demonstrated and documented for no less than 12 consecutive months.
Must have working knowledge of the English language, including reading, writing, and speaking English.
Use of a computer, keyboard, and mouse and experience with basic Microsoft Office applications, required. Must possess the computer skills necessary to complete work assignments, online learning requirements for job specific competencies, access online forms and policies, complete online benefits enrollment, etc. Use of number pad on keyboard preferred.?
Ability to search resources and/or Internet to locate CMS and third party payer websites for coding requirements and medical necessity guidelines is required.?
Competent in accessing and using an encoder (3M or Trucode), required.
Communication: Excellent written and oral communication skills and the ability to work independently with minimal supervision, required. Legible penmanship required.