Job Title:
HIM Coding Specialist
Cost Center:
Health Information Management
Job Description:
The HIM Coding Specialist is responsible for coding accurately, diagnoses and procedures utilizing the International Classification of Diseases, Clinical Modification (ICD-9/10-CM) and/or the Current Procedural Terminology (CPT) coding systems. Assigns ICD-9/10-CM codes in the proper sequence to reach the appropriate DRG. Minimum Qualifications o Education o Completion of required course work and/or degree for accreditation or registration with the American Health Information Management Association (AHIMA). o Credentials o State Required: None o GPRMC Required/Preferred: Required are accreditation as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) with the American Health Information Management Association (AHIMA). Also, a recent Health Information Management (HIM) or Health Information Technology (HIT) graduate is preferred if accreditation is successfully completed within 6 months of employment. Membership in Clinical Coding Society (a division of AHIMA) is preferred. Physical Demands 1. Stand and/or walk frequently. 2. Sit frequently. 3. No lift and/or carry. 4. No push and/or pull. 5. Visual acuity and manual dexterity within normal limits. 6. Bend, stoop, and crouch occasionally. 7. Reach floor to overhead occasionally. 8. Computer use frequently.
Essential Functions
1. Demonstrates competency in Medical Record Abstract, Medical Record Control, Medical Record Index, and DRG/Case Mix applications in Affinity system. Demonstrates competency in using 3M Encoder. Demonstrates competency using ChartMaxx imaging system.
2. Abstracts and verifies information such as service codes, time of discharge, surgical data, transferring status, observation times, and physician relationship (admitting, attending, primary care, consulting, surgeon, assistant surgeon, etc.) from the medical record. Codes on records of patients under Series Outpatient Service Codes, Parent Accounts prior to the end of the month in which the Parent Account was created, if possible. Checks for uncoded Child accounts on said records on a routine basis.
3. Demonstrates competencies established by Department Director/Coding DRG Coordinator. Demonstrates competency in ICD-9/10-CM and CPT coding by coding pursuant to coding rules of said coding systems.
4. Assigns diagnostic and operative/procedure codes for inpatient and outpatient records, utilizing ICD-9/10-CM. Assigns CPT codes and Revenue Codes on Emergency Department (EDA/EDS service codes), Same Day Services (SDS), and other patients who have undergone outpatient procedures.
5. Reviews each medical record to be coded, ensuring that there is sufficient documentation to support the ICD-9/10-CM or CPT-4 codes assigned. Checks deficiencies and inconsistencies in the medical record. Obtains, either personally or in cooperation with other HIM staff, GPRMC staff, or physicians, any missing medical necessity documentation.
6. Demonstrates ability to reorganize work in order to satisfy fluctuations in volume and staffing adjustments. Codes records as assigned and prioritized by the Coding/DRG Coordinator.
7. Reviews APC edits on outpatient accounts and add modifiers when necessary to produce clean billing claim,
8. Provides coding assistance to Home Health in the absence or direction of the Coding/DRG Coordinator.
9. Participates in audits of medical records for coding accuracy. Actively participates in education opportunities for continuing education and professional growth.
10. Performs other duties as assigned by Coding/DRG Coordinator or HIM Director.
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