Coder 1 - Clinic

The Clinic Coder 1 abstracts clinical information from a variety of medical records, charts and documents and assigns appropriate ICD-10 and/or CPT-4 codes to patient records according to established procedures. Familiar with standard concepts, practices, and procedures within a particular field. Relies on instructions and pre-established guidelines to perform the functions of the job. May work with coding databases and confirms DRG assignments. This position relies on established guidelines to accomplish tasks and works under close supervision.

Responsibilities

1. Coding/Abstracting
   1. Determines the sequencing of diseases, diagnoses, and surgeries. The Coder accurately assigns appropriate codes to patient records, including ambulatory surgery, treatment type admission, observation, emergency room, and outpatient lab/radiology, using ICD-10-CM system and CPT-4 guidelines. Abstracts data elements such as discharge disposition, Consultants, Anesthesiologists, Operating Room Assistants, and verifies the correct status has been assigned to outpatient records.
   2. Communicates with the appropriate HIM staff members when records with missing information are identified. This is in an effort to foster effective health information management and ensure the provision of high quality health care services.
   3. Assists the Business Office and external agencies in clarification of coding regarding reimbursement issues. Handles all requests in a timely fashion.
2. Quality/Performance
   1. Maintains an accuracy rate of not less than 93% based on internal and/or external review and productivity standards, engages in problem identification and resolution, and assists in data gathering and chart auditing.
   2. Demonstrates competencies in the service to our patients/customers of all ages by obtaining information in terms of customer needs. Speaks in a positive, professional manner about co-workers, physicians, and the facility.
   3. Attends meetings as required and strives to improve the quality of meetings by taking an active role in meeting topics. Participates in educational programs, in-services and training sessions as required. When appropriate, theCoder shares his/her own expertise with others in an effort to further the quality of education and personal growth provided to new personnel, volunteers and interning students.
3. Other Duties as Assigned
   1. Performs other duties as assigned or requested.

Qualifications

Experience - 1 year experience in medical coding. Certification as a Professional Coder-Apprentice (CPC-A) through AAPC may substitute for required experience
Education - High School or equivalent