Medical Billing and Coding

• Reviews and interprets medical information, physician treatment plans, course, and outcome to determine appropriate ICD-10 CM/CPT codes for diagnoses and procedures. ( 65%)
• Abstracts data elements to satisfy statistical requests by the hospital, health system, medical staff, etc. and enters all coded/abstracted information into designated system. ( 15%)
• Ensures efficient management of medical information and cash flow as it pertains to the unbilled coding report. ( 10%)
• Keeps informed of the changes/updates in ICD-10 CM/CPT guidelines by attending appropriate training, reviewing coding clinics and other resources and implementing these updates in daily work. ( 5%)
• Performs other duties as assigned or required. (5%)

Coder – Outpatient

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – Cardiology

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings, ensuring expert application of modifiers and E/M guidelines
• Perform entry-level facility coding for simple outpatient encounters (e.g., diagnostic imaging, labs) and basic inpatient services (e.g., uncomplicated admissions, short stays) using ICD-10-CM and ICD-10-PCS, where applicable
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – ENT, Audiology

Coder – Outpatient, Part-Time

• Coding/Abstracting
• 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.
• 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.
• Assists the Business Office and external agencies in clarification of coding regarding reimbursement issues. Handles all requests in a timely fashion.
• 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.
• 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.
• 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, the Coder 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.
• Performs other duties as assigned or requested.

Coder 1 – Clinic

• Responsible for assisting the coding department with the day-to-day non-coding duties support activities
• Assigns codes to office-based visits and procedures using the International Classification of Diseases (ICD-10-CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
• Resolve coding edits to assure accurate and complete claims submission
• Sequences diagnoses and procedure codes as outlined in CPT, ICD-10-CM, and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines
• Reviews all clinician documentation to support assigned codes in the health information record
• Follows up and obtains clarification of inaccurate documentation as appropriate
• Codes risk adjustable encounters, resolves CRMs, and trends coding denials, as assigned
• Conducts formal coding and documentation reviews, clinician reviews and quality reviews, as assigned
• Assists with coding research functions and education activities
• Creates clinician coding and documentation education based on query trends or ad-hoc requests
• Adheres to the organization and departmental guidelines, policies, and protocols.
• Abides by Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement
• Maintains confidentiality of patient.

Physician Support Coder

• The Medical Coder 3 (inpatient and ambulatory surgery) abstracts clinical information from a variety of medical records, charts and documents and assigns appropriate ICD-10 - CM/PCS and CPT codes to patient records according to established procedures.
• Works with coding databases and confirms DRG assignments.
• 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.
• This position relies on guidelines and some experience and judgment to complete job and works under general supervision.

Coder 3 – Hospital

• Evaluate medical records and provide clinical and surgical abstraction
• Accurately code diagnostic and procedural information
• Consult with medical providers for record clarification
• Ensure compliance with coding rules and regulations
• Compile reports and tabulate data from medical records
• Identify validation edits and ensure accurate coding
• Work independently under regular supervision

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