Coder I (PRN)

Assign ICD-10-CM, CPT-4, HCPCS, and modifier codes to the highest level of specificity based on documentation in the medical record, in compliance with all governmental regulations and hospital policies. Review data quality and documentation to facilitate improvement. Review medical records and assigned charges as needed to ensure accuracy.

Essential Functions

• Apply appropriate outpatient coding guidelines according to patient type.
• Code the Reason for Visit (RFV) using the patient’s own words describing why they are seeking services.
• Assign the principal diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care,” in accordance with Cibola General Hospital’s Coding, Abstracting, and Data Retrieval Policy and AHIMA’s Standards of Ethical Coding.
• Review secondary diagnoses in the medical record for clarification, agreement, comorbidities/complications, and additional relevant information.
• Identify accounts that cannot be coded or abstracted, place them on hold with the appropriate hold reason, and notify the HIM Director of any issues preventing final coding.
• Query attending physicians via the Cerner message center using a compliant query process when additional clarification, specificity, or correct sequencing is needed.
• Enter final coding and abstracting data into the 3M system through the Cerner electronic medical record (EMR).
• Maintain a minimum coding accuracy rate of 95%.
• Work assigned coding queues in Cerner and run a daily Discharged Not Final Coded (DNFC) list to identify and process all outstanding accounts.
• Code and abstract discharged inpatient and outpatient charts within 3 days of discharge. Notify the HIM Director of any barriers affecting timely coding.
• Assist the HIM and PFS Directors in resolving coding-related issues on denied claims.
• Support maintenance of the hospital charge master by identifying and requesting addition of missing codes.
• Provide support to hospital administration on special projects related to operational and financial performance as requested.
• Participate in Performance Improvement projects as assigned and demonstrate understanding of the hospital’s performance improvement processes.
• Perform other duties as assigned.

Education and/or Experience

• Current RHIT, CCS, CCS-P, or CPC certification required.
• Minimum of 1 year of outpatient coding experience.
• Extensive knowledge of medical terminology, anatomy and physiology, and disease processes.
• Strong working knowledge of ICD-10-CM, CPT-4, HCPCS, modifiers, and prospective payment systems.
• Proficient computer skills, including Microsoft Outlook, Word, Excel, and 3M coding software.
• High attention to detail and accuracy.