Coder II | UF Heart & Vascular; REMOTE

Overview

Fully Remote, Must live in Florida
. Orientation onsite in St Augustine first 2 days

• Assigns correct ICD-10-CM code to all diagnoses and correct CPT code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical record to retrieve proper documents (discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity.
• Reads and understands operative reports to classify to the most accurate CPT codes. Researches complex operations as necessary.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Assigns correct modifiers on CPT codes that are required under the Medicare APC reimbursement.
• Maintains thorough knowledge of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies. Maintains a positive working relationship with physicians to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains thorough knowledge of the prospective payment system and any new codes or DRGs added/changed each year. Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as ICD-9-CM coding conventions, Coding Clinic, and other official resources to substantiate the most appropriate, correct code assignment. Stays abreast of Medicare’s medical review policies and incorporates updates and changes into the coding process.

Education / Training

• High School Diploma/Equivalent

Preferences

• Graduate of a Health Information Management Program

Experience Requirements

• 1-year Medical Record Coding

Certificates/Licenses/Registration

• Any AAPC or AHIMA Medical Coding Certification