Job Description

Job Summary 

As a member of the HIM department, the Outpatient Coder provides coding assistance for hospital outpatient areas, including the Emergency Department, observation, outpatient surgery, and ancillary services. Under the direction of the HIM Director, the coder reviews patient records and assigns accurate ICD-10-CM and CPT/HCPCS codes for diagnoses and procedures. This role requires independent decision-making to ensure correct code assignments, familiarity with LCD/NCD guidelines, and the resolution of coding edits. These decisions will play a key role in determining reimbursement potential while ensuring compliance with coding standards and corporate billing policies. 

Essential Functions

Evaluates medical record documentation to ensure appropriate assignment and sequencing of the correct diagnostic and procedure codes for services and treatments as documented in the health records. Maintains a working knowledge of CPT, HCPCS, and ICD coding principles, governmental regulations, protocols, and third party requirements regarding billing and documentation. Reviews clinic notes, H&Ps, consults, procedures, and surgeries to apply accurate CPT coding and ICD-10 coding to the highest specificity. Monitors and makes necessary changes to any charge under review using medical records and physician documentation. Communicates with physician/provider when clarification is needed regarding documentation that impacts outcome of coding. Documents clearly any coding steps taken on account for clear history of actions. Maintains productivity standards on a regular basis as evidenced by ability to complete tasks and remain current within scheduled hours per week. Works coding, coding related holds, bill errors, and edits. Applies correct coding hierarchy to CPT and ICD-10 codes. Maintain minimum quality standards of 95% accuracy. Provides data for administration review and/or audits. Assist management with any special projects related to coding and education. Communicates with coders, billers, managers, and physicians/providers in a respectful, constructive, and professional manner. Maintains confidentiality with patient’s financial, personal, and medical information according to HIPAA guidelines. Performs other duties as assigned. Complies with all policies and standards.

Qualifications

Technical School Graduate of a Medical Coding Program required Associate Degree in HIM or healthcare, medical records, or related field preferred 2+ years of experience in hospital coding required 1-2 years Experience working in electronic health records and encoders required

Knowledge, Skills and Abilities

Knowledge of related prospective payment systems, anatomy, physiology, ancillary testing, and medical terminology. Experience with virtual desktop image, electronic medical record systems, encoding systems as well as word processing and spreadsheet software. Knowledge of medical terminology, anatomy, physiology, and pharmacology. Ability to maintain confidentiality of patient information in accordance with HIPAA guidelines. Ability to work effectively with co-workers, management and physicians. Ability to read and understand oral and written instructions and follow written protocols.

Licenses and Certifications

Certified Coder-AHIMA or AAPC Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) required or CCS-Certified Coding Specialist required or RHIT - Registered Health Information Technician required or RHIA - Registered Health Information Administrator required or CCA - Certified Coding Associate required