Summary

The Coding Specialist is responsible for accurately assigning and sequencing ICD diagnostic and procedural codes and/or CPT procedural codes to inpatient and outpatient records.

Essential Duties and Responsibilities

Code diagnostic and procedural information from the record using ICD and CPT/HCPCS classification systems Utilize a computerized encoding system to facilitate accurate coding Sequence diagnoses and procedures by following the ICD, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal Intermediary guidelines Work cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure quality coding Select the APC for each outpatient visit, ensuring coding compliance based on approved coding guidelines and conventions Abstract medical data from the record to complete a discharge abstract on each inpatient, ambulatory surgery, emergency room, outpatient, and ancillary visit, completing and verifying diagnostic and demographic information Enter patient information into computerized inpatient and outpatient medical record databases Ensure the accuracy and integrity of medical record abstract data prior to billing interface and claims submission. Code outpatient, emergency department and outpatient diagnostic records as determined by Coding Operations Manager. Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate Communicate and advise the Patient Accounts on coding and APC assignment and submission Review chart documentation for accurate diagnosis and procedure reporting for medical necessity and other edits. Complete other duties as assigned.

Summary of Other Job Duties and Expectations

Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center Exhibit excellent customer relations to patients, visitors, physicians, and co-workers Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties

 

Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting  positive work and customer environments Work as a team to continuously improve work quality Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care Present self in a positive manner as reflected by personal attire, etiquette, and behavior

Attend required hospital-wide orientations, meetings, and in-services

 

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education: Completion of an approved coding program with AHIMA or AAPC approval status

Preferred Education: N/A

Experience: 3+ years recent experience coding in an acute hospital setting required; coding ability will need to be demonstrated via a skills assessment

Certificates, Licenses, Registrations

Qualified applicants must have one of the following certifications: CCS, CIC, COC, RHIA, or RHIT or other coding certification through AHIMA and AAPC..