Codes Outpatient Diagnostics, Recurring and/or Emergency Department accounts. Reviews clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM and CPT-4 codes for hospital reimbursement, medical necessity, mortality & morbidity outcomes, governmental compliance coding, research, statistics, and regulatory compliance. Under the direction of the Health Information Management Coding Manager, accurately codes outpatient encounters diagnosis, procedures and/or modifiers that are supported by the health record in accordance with ICD-10-CM Official Coding Guidelines for Coding and Reporting. Abstracts, codes and assigns necessary demographic and clinical data elements required for outpatient records. Effectively utilizes encoder software to ensure appropriate reimbursement and accurate APC assignment. Completes all work in accordance with defined productivity and quality standards. As necessary, queries and/or submits request to the physician for additional information or clarification of diagnoses, co-morbid/secondary conditions, and procedures. Assures coding practices fall within established compliance guidelines. Performs other related duties as requested by HIM management.
High School Grad or Equivalent
Required: Medical Terminology - Previous experience
Preferred: Coding - Previous experience
Required: None, unless noted in the “Other” section below
Preferred: Cert Coding Specialist, Certified Outpatient Coder
None, unless noted in the “Other” section below
6 months of outpatient coding preferred. Certified Coding Associate (CCA) also accepted. Knowledge of ICD-10-CM and CPT coding (or most current healthcare industry numerical coding system) procedures required. CCS, CIC or CPC required within 1 year of hire. Successful completion of an AHIMA certified coding program preferred. Knowledge of anatomy & physiology - required