Essential Functions of the Job:
1. Review the Chart Progress Notes, patient documentation and the ICD-10 codes for diagnoses, procedures, and services performed by physicians and other qualified healthcare providers.
2. Verifies all diagnostic procedural codes from the electronic health record using ICD-10 and CPT coding classifications.
3. Communicates effectively with providers concerning diagnoses and procedure(s) to assure proper coding and reimbursement.
4. Identify all chargeable items within each progress note to ensure proper CPT/HCPCS codes for each of the items.
5. Apply sequencing guidelines for the diagnosis codes and selection of the principal diagnosis and procedure according to ICD-10 guidelines
6. Tracks open/close encounter reports to assure that all patients seen in the clinic are properly coded.
7. Organizes & prioritizes all work to ensure that records are coded in time frames that will be in line with department policies.
8. Maintains knowledge of Anatomy & Physiology to interpret general medical classifications for coding including the most complicated encounters/cases.
9. Acts as an expert resource person to other coders & personnel in other departments regarding coding questions & issues.
10. Participates in ongoing education, including in-service training and other activities to maintain and improve competence.
11. Performs any other related job duties as assigned and/or requested
Education Required (Minimum Level of Education): High School Diploma or GED Equivalent.
Certifications/Licenses Required: Current Procedural Coder (CPC) Certification from the American Academy of Professional Coders (AAPC) required. Medical Terminology Certificate.
Preferred:Associate Degree in Health Information Technology preferred. Credentialed as a Registered Health Information Technician (RHIT).
Experience Required (Minimum Level of Experience):One year of medical coding experience required with CPC certification; Two (2) years of medical coding experience and ICD-10 training completed, if certification is pending. CPC Certificationmust be obtained for ICD-10 CM within six 6 months of employment.
Verbal and Written Skills Required to Perform the Job: Good oral and written communication skills. Good customer service skills.
Technical Knowledge and Skills Required to Perform the Job: Extensive knowledge of medical terminology, human anatomy and physiology, current medical techniques, procedures and medications. Knowledge of diagnostic test, procedures, pathology terms and drug reference books. Knowledge of ICD- 10-CM and HCPCS/CPT coding & abstracting procedures. Proficient in typing skills and experience with using computers and software systems.
Equipment Used: Computers, Software systems, telephones, Scanner, Copy & Fax Machine