Coding Specialist Inpatient
Full Time 80 hours, Days Monday – Friday
The Coding Specialist is responsible for coding patients’ medical charts. The employee must maintain effective communication and good working relationships with the revenue cycle personnel, other departments, Medical Staff and the public, in conjunction with organization policies.
- Completes charge sheets for departments that do not electronically generate charges.
- Read and interpret health record documentation to identify all diagnosis and procedures that affect the current inpatient, outpatient or clinic encounter.
- Assess the adequacy of health record documentation to ensure that it supports all diagnosis and procedures to which codes are assigned.
- Accurately identifies and codes the principle and secondary diagnosis for all clinic, outpatient and/or inpatients using ICD-10-CM in accordance with established coding rules and guidelines.
- Accurately identifies and codes all ICD-10-CM procedure and CPT procedures in accordance with established coding rules and regulations.
- Queries physicians when code assignments are not straight forward or documentation in the records is inadequate or unclear for coding purposes.
- Correctly abstracts the required patient data from the record in the computer system in conjunction with code assignments to ensure accurate information for billing and index purposes.
- Applies knowledge of anatomy and physiology and medical terminology to assign accurate codes to diagnoses and procedures.
- Demonstrates ability to recognize potential coding quality issues from an array of data.
- Must be skilled in the use of a PC, encoding and word processing software and transcription equipment.
- Serves as a review for accurate and complete assembly and analysis of health records.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Experience coding with ICD-10-CM and CPT classification
- Good communication skills both written and verbal, accuracy, attention to detail, basic computer knowledge and typing skills
- Must have the ability to work alone without the direct supervision and be able to make independent decision when circumstances warrant such action.
- Must posses the ability to seek out and accept new methods and principles and be willing to incorporate them into the department routine.
Successfully completed an approved ICD-10-CM and CPT coding program. Experience using encoder and grouping software and computerized medical information system. Minimum of 3 years coding experience; 5 years of experience preferred.