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The Coder II abstracts medical data and assigns accurate ICD-10 and CPT codes based on clinical documentation. They also coordinate with physicians and staff to ensure accurate billing and provide education on documentation standards.
ESSENTIAL FUNCTIONS
Abstracts data in compliance with national, regional, and local policies, and interprets and reviews medical record documentation to assign accurate ICD-10 diagnosis and CPT procedure codes.
· Utilizes practice management system (PMS) to accurately account for demographics and services performed for all scheduled and unscheduled surgical cases according to standard procedures and coding guidelines.
· Utilizes individual hospital medical record systems and coordinates with physicians and staff to obtain clinical documents and demographics required for appropriate coding and billing for all hospital procedures.
· Provides education and support to clinical areas regarding appropriate documentation and coding of services to achieve accurate billing. Maintains effective communication with providers concerning coding issues.
EDUCATION
· High school diploma/GED or equivalent working knowledge preferred.
· Accredited by the American Health Information Management Association (CCS-P) or the American Academy of Professional Coders (CPC)
EXPERIENCE
· At least three years of experience in provider coding and medical terminology with extensive knowledge of ICD-10, CPT, and HCPC coding required.
· Preferred specialty experience in areas of Orthopedics, Neurology, Physical Medicine, and Rehabilitation or Pain Management.
REQUIREMENTS
· A minimum of one of the following credentials: CCS-P or CPC.
· Meets established coding and abstracting quality and productivity standards.
· Experience with various coding software. Previous experience with remote coding is preferred. Possesses PC skills, both keyboarding and applications.
· Requires a good understanding of anatomy, physiology, medical terminology, and disease processes.
· Ability to work independently.
· Excellent attention to detail.
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