Coder II, HIM - HIM Financial Non-Exempt; Non-Union

Overview

In accordance with federal coding compliance regulations and guidelines, use current ICD-10-CM, CPT-4, and HCPCS code sets/systems to accurately abstract, code, and electronically record into the 3M Coding & Reimburse System (3M-CRS) & the coding abstracting system (3M-Clin Trac), all diagnoses, surgical procedures, and other significant invasive and non-invasive procedures documented by any physician in outpatient medical records (i.e. OP Ancillary/Clinic Visits, and assorted outpatient surgeries: GI Lab, Heart Cath Lab, Pain Management surgery, and Invasive Radiology, etc.).

Address OCE/NCCI edits within 3M-CRS and those returned from the Business Office. Understands PFS coding/billing processes & systems such as PBAR and nThrive/Med Assets/XClaim to assure timely claims drop with appropriate codes. Performs other coding department related duties as assigned by HIM management staff.

• Ambulatory Surgery coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, CPT/HCPCS, and Modifier classification systems; abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions.
• Review the entire medical record; accurately classify and sequence diagnoses and procedures; ensure capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co-morbidities, historical condition or family history that impacts current care or treatment, and all external causes of morbidity.
• Enter patient information into inpatient and outpatient medical record databases (Clin Trac/HDM); ensure accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission.
• Work cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist to obtain documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes.
• Assist in the correction of regulatory reports, such as OSHPD data, as requested.
• Maintain attendance, punctuality, and professionalism in all HIM Coding and related activities.
• Demonstrate reliability for completion of tasks, duties, communications, and actions; complete tasks accurately, legibly, and in a timely fashion.
• Perform other duties as requested/assigned by Director, Manager, Supervisor, or designee.
• Achieve a minimum of 95% coding accuracy rate as determined by internal or external reviews of coding and/or department quality reviews.
• Achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by internal or external reviews of coding and/or department quality reviews.
• Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting.
• Recognize education needs based on monthly reviews and conduct self-improvement activities.
• Act as a resource to coding and hospital staff on coding issues and questions.
• Improve MS-DRG assignments for documentation & coding of PDx, Sec Dx, CC/MCC, PPx, and Sec Px in accordance with coding laws, regulations, rules, guidelines, and conventions.
• Improve APR-DRG, SOI, and ROM assignments for the same scope.
• Improve APC/HCC assignments for medical necessity documentation & coding in accordance with coding standards.
• Maintain minimum expected productivity standards and strive for steady productivity with consistent effort.
• Process coding queues/task lists to ensure 95% of patient bills are dropped within 5 days after discharge/date of service, with remaining 5% within 2 weeks.
• Assist other coders and answer questions as needed.
• Assist Patient Financial Services (PFS), Patient Access, and other departments in addressing coding issues to generate interim bills as needed; assist physicians, office staff, and hospital departments with coding questions.
• Monitor unbilled accounts to ensure oldest records are coded and prioritized.
• Maintain AHIMA and/or AAPC coding credentials as specified in the job description.
• Attend coding & CDI seminars, webinars, and in-services to maintain annual CEUs.
• Keep up-to-date with ICD-10 Official Guidelines for Coding & Reporting, AHA Coding Clinic, and CPT Assistant.
• Review other professional journals and newsletters to maintain coding knowledge.
• Attend and actively participate in daily huddles; adhere to HIM policies and procedures.
• Communicate changes to improve processes to the director as needed.
• Participate in department quality improvement activities and processes (e.g., Performance Improvement).
• Work and communicate positively with management, staff, medical personnel, and external customers.
• Communicate effectively intra- and inter-departmentally and with external customers.
• Provide timely follow-up with written and verbal requests for information.
• Navigate the Electronic Health Record (EHR):
  Cerner/Power chart & Coding mPage.
• Navigate and use 3M-CRS Encoder to…