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Assigns accurate ICD-10 and CPT-4 codes to outpatient medical records to ensure proper reimbursement and regulatory compliance. Monitors daily coding workflows to meet established productivity and quality accuracy standards.
Under direct supervision, assigns accurate ICD-10 diagnoses and CPT-4 procedure codes derived from medical record documentation for Emergency Room (ER), ER E/M charging, OP Trauma, Observation, Series/Recurring, Clinics, minor surgery, and other ancillary outpatient facility encounters for the purpose of appropriate reimbursement, research, and compliance with federal and state regulations. This role is essential for ensuring accurate and timely coding of medical records which directly impacts reimbursement and compliance.
Primary Responsibilities
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job responsibilities performed.
· Identifies and assigns ICD-10 diagnostic codes and CPT-4 procedure codes to outpatient visits including Emergency Room (ER), ER E/M charging, OP Trauma, Observation, Series/Recurring, Clinic, minor surgery, and other ancillary visit locations for the purpose of hospital reimbursement, research, and compliance with federal and state regulations.
· Monitors assigned work on a daily basis in order to facilitate the billing process within the established timeframes. Codes and abstracts records within timeframes established for each patient type.
o Maintains coding quality accuracy rate of 90%.
o Maintains productivity rate of at least 95%.
· Complies with AHIMA standards of ethical coding and coding compliance guidelines.
· Demonstrates support and compliance with University of Maryland Medical System mission, vision, values statement, goals and objectives and policies. Performs other duties or projects such as coding corrections as assigned by the manager.
· Performs related duties as assigned.
· High school diploma or equivalent. Formal ICD-10-CM and CPT training is required.
· 6 months – 2 years of outpatient coding experience in a facility healthcare setting.
· Must have one of the following: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Outpatient Coder (COC).
Education & Experience - Preferred
· Associate or bachelor’s degree is preferred.
Knowledge, Skills, & Abilities
· Ability to utilize coding and EHR software (e.g., EPIC, 3M HDM) efficiently to perform coding duties.
· Strong analytical and organizational skills.
· Ability to prioritize workload, meet deadlines, and work effectively under pressure.
· Excellent customer service skills.
· Knowledge of general office procedures and filing systems.
· Strong problem-solving skills.
· Ability to work under minimal supervision.
· Familiar with basic medical terminology.
· Strong computer skills and typing ability.
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