Coder - Full Time - Days

Interprets clinical documentation/records of basic outpatient cases to ensure all diagnoses and procedures are documented and coded.

KNOWLEDGE AND SKILLS:

Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.

EDUCATION: CPC-H, CPC, or CCA with 2 yrs. Hospital coding experience or RHIA, RHIT, CCS, CCS-P or 5 or more years of hospital coding strongly preferred. Skills assessment required determining competency level of coding skills and outcome determines placement in intermediate to advance level.

YEARS OF EXPERIENCE:

REQUIRED SKILLS AND KNOWLEDGE:

Criteria:

Skills*:

Coder Level I:

Basic outpatient cases with simple diagnoses and procedures.

• assigns "V" and "E' codes
• outpatient diagnostic testing

Coder Level II:

Can code 2 types of outpatient cases such as OP and ED or OP and Ambulatory with some outpatient procedures/or inpatient cases.

Coder Level III:

Complex outpatient cases and/or inpatient cases.

• same day surgeries
• endoscopy
• cardiac Cath
• interventional Radiology

Coder Level IV:

Codes any case including the most complex cases.

Education:

Coder Level I:

Successful completion of some coursework or formal education in:

• ICD9CM
• Disease process

Medical terminology

Coder Level II:

Successful completion of coursework or formal education in:

• ICD9CM
• Disease process

Medical terminology

Coder Level III:

Successful completion of advanced coursework or formal education in:

• ICD9CM
• CPT
• Disease process

Medical terminology

Coder Level IV:

Successful completion of advanced coursework or formal education in:

• ICD9CM
• CPT
• Disease process

Medical terminology

• Each increase in levels assumes the ability to code at the previous skill level.

CERTIFICATIONS & CREDENTIALS:

The following certifications are preferred:

• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Coding Associate(CCA)
• Certified Coding Specialist Physician Based (CCS-P)
• Certified Professional Coder - Hospital (CPCH)
• Certified Professional Coder (CPC)
• Applicable associate or bachelor degree

A. Interprets clinical documentation/records to ensure all diagnosis and procedure documentation is coded.

B. Applies regulatory and facility guidelines while coding.

C. Code clinical documentation with an accuracy rate consistent with the hospital quality program.

Abstract clinical information from the medical record into the clinical information system with an accuracy rate consistent with the hospital abstracting quality program. The inpatient and outpatient abstracting policy should be referenced for specific on TCH abstracting practices.

Documentation

A. Interprets health record content to ensure that all diagnoses and procedures assigned are supported by physician documentation.

Productivity

A. Coder will code and abstract medical records at a productivity rate that is consistent with the hospital productivity program.

Participates in continued quality improvement opportunities

Other duties as assigned