Responsible for coding and abstracting diagnoses and procedures from patient charts using ICD-CM, ICD PCS and/or CPT-4/HCPCS codes for statistical and reimbursement purposes for all Billings Clinic inpatient and outpatient services. Alternatively, since Billings Clinic is an integrated delivery system, responsible for auditing or assigning CPT and E&M codes to clinic encounters by reading dictation, reviewing problem lists and intake forms, capturing primary and secondary ICD-CM diagnoses, adding HCPCS modifiers where necessary and verifying units of service for pharmacy items and supplies. Queries physicians to clarify clinical documentation. Educates physicians either concurrently or after-the-fact on coding and documentation and serves as an on-site resource for providers and staff. Calculates the MSDRG and APR- DRG. Ensures adherence to all Billings Clinic and regulatory compliance policies and procedures governing medical records coding, billing and reimbursement.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Maintains a detailed knowledge of and ensures adherence to all applicable Billings Clinic and regulatory compliance policies/procedures governing medical record coding, insurance billing and reimbursement methodologies in all aspects of the job. Actively seeks out clarification and/or updated information to ensure most current guidelines are followed.
• Review of medical records for documentation to identify the principal diagnosis and/or procedure and all applicable secondary diagnosis and procedures
• Assigning the appropriate ICD-CM, ICD-PCS and/or CPT-4/HCPCS codes for each encounter utilizing ICD-9 and CPT-4 books.
• Utilizing the computerized encoding system and/or coding books to facilitate accurate coding and sequencing of diagnosis and procedures by following all regulatory compliance policies and procedures governing medical records coding, billing and reimbursement.
• Calculating a DRG or APC for each inpatient visit/encounter and/or physician visits/services coding to appropriately and legitimately and ethically optimize the payment based on approved coding guidelines and standards
• Assigns POA for inpatient facility coding.
• Captures any missing charges.
• Maintains or exceeds 95% coding accuracy based on audit findings.
• Maintains or exceeds department productivity standards for assigned areas of coding.
• Identifies and reports any regulatory or compliance concerns to Manager, Director and/or Billings Clinic Corporate Compliance Department.
• Ensures accuracy of data prior to billing interface and claims submission. (i.e. discharge disposition, appropriate use of modifiers, CPT,ICD, preforming provider, date of service, POA, NCCI and other coding edits, etc. )
• Collects data from the medical record to complete a discharge data abstract on each encounter for specialized studies.
• Communicates with physicians/Non-Physician Providers to provide coding and documentation education and feedback.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements. Maintains knowledge of current information and technologies for coding and abstracting arena.
• Maintains competency in all organizational, departmental and outside agency environmental, employee or patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization.