Job Summary:

The HIM Coder II reports to the Coding Manager and may code any of the following account types: outpatient, single path surgical accounts to include both the abstract and the professional claim, ED, and/or ambulatory accounts.  This role analyzes medical records in order to code and abstract medical information to be submitted to financial reimbursement as required for the Uniform Bill and for the DRG/Prospective Payment System.

Education and Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are the knowledge, skill, and/or ability required.

High School Degree or equivalent AHIMA or AAPC Coding Credential (CPC, COC, COC-A, CIC, or CCA, CPC-A, CCS, CCS-P, RHIT, RHIA) 1-2 years coding experience in professional specialty coding and/or ICD-10 CM/PCS

Preferred Qualifications:

Associates Degree Meditech Experience 3M Computer Assisted Coding Experience

Essential Duties and Responsibilities:

Reads and reviews health records, identifies appropriate diagnoses and procedures and assigns appropriate codes for outpatient facility and/or professional charges Abstracts clinical data from health records and assigns appropriate ICD-10-CM/PCS and CPT codes, as applicable.  These codes are used for classification, reimbursement, strategic planning, and research Remains up to date on all regulatory and private payor policies, compliance policies, and coding updates or changes Creates account for professional fee charges if not through abstracting for surgeon and anesthesia, as needed Maintains a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM and CPT coding guidelines to outpatient diagnoses and procedures Correlates information from approved supporting clinical documentation not limited to Pathology, Radiology, and the surgical operative report Abstracts all clinical data with high degree of accuracy to be utilized in research and benchmarking by the hospital as well as numerous third parties such as KHDE, HIDI, and CMS Communicate with ancillary services personnel for needed documentation for accurate coding Provides real-time feedback to surgical/procedural providers as it pertains to proper coding and clinical documentation of services performed Maintains and processes claim edits to assure timely billing Works collaboratively to achieve minimum bill days from discharge/service date for assigned accounts Coders maintain prioritized workflow through cooperative work distribution (i.e. prioritization of charts by discharge date and total charges) Works cooperatively with team-mates to include process improvement projects, cross-training, or assisting with questions in coder's area of expertise. Performs other related duties incidental to the work described herein

Infection Control: Initial and Ongoing trainings could include but are not limited to, blood borne pathogens, bodily fluids and bio hazardous materials as it applies to your daily work environment.

Patient Interaction: No Contact

HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary – required (routine) to do the job;
Secondary – required for the job, but mostly be exception; and
None – no approved access

Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion

Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical

Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates

Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes